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TABLE8.16 Dierent types ofbandages.
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Type Explanation Characteristics Applicability
Type 2 bandages (Hopkins and
Worboys2005).
Dose varies according to the
variables highlighted in Laplace’s
law. It is estimated that in a
standard limb circumference one
mercury pressure; in a larger
ankle circumference a second
layer is advised.
Other factors may also aect the
dose of the compression, for
example the person’s height, or if
they have an occupation where
they are standing all day (It is
worthy of note that other types of
non- compression bandages such
as crepe bandages fall within the
Type 2 bandage category within
the British National Formulary).
Inelastic bandages, also known as short
stretch bandages.
FIGURE8.12 Inelastic
bandage.
Source: Courtesy of L&R.
Have limited
extensibility and are
applied at full
stretch. They have
no elastomer bres,
but sculpt the limb
like a
supportive cast.
Have low resting
pressures and high
working pressures.
Support the calf
muscle pump and
lymphatic system in
returning blood and
lymphatic uid.
Occlude the veins
intermittently
with movement.
Can be used in the presence
or absence of oedema.
Can be used in mobile and
immobile patients.
Can be used for palliative
bandaging and sports,
but only if additional
education in these elds
has been undertaken.
Type Explanation Characteristics Applicability
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The term ‘two- layer’ should be rejected
because in very thin limbs only one layer
may be used. Similarly, in advanced practice
layering is applied in a specialist manner
that does not sit within two- layer frame
works. In standard care inelastic bandages
are applied at full stretch in a spiral manner
with a 50% overlap; in advanced practice
this can vary.
FIGURE8.13 Applying an inelastic
bandage.
Source: Courtesy of L&R.
Brand examples include Actico and
Comprilan.
(Continued)
TABLE8.16 (Continued)
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Type Explanation Characteristics Applicability
Type 3 compression bandages
Type 3a 14–17 mmHg
It is important to note that the dose
varies according to Laplace’s law.
It is predicted that in a standard
limb circumference the bandage
should achieve 14–17 mmHg
mercury pressure; in a larger
ankle circumference a dierent
bandage is advised (Hopkins and
Worboys2005).
Type 3b 18–24 mmHg
Dose varies according to Laplace’s
law. It is predicted that in a
standard limb circumference the
bandage should achieve
mmHg mercury pressure
18–24
(Hopkins and Worboys2005).
Type 3c (25–35
(extra-
bandages (Hopkins and
Worboys2005).
mmHg) and Type 3d
high compression)
Elastic bandage.
Light compression bandage.
Also known as long stretch.
Terms such as three- and four- layer should
be rejected.
In standard care they are applied in a gure of
eight at 50% stretch.
Elastic bandage.
Moderate compression bandage.
Also known as long stretch.
Terms such as three- and four- layer should
be rejected.
In standard care they are applied in a spiral
manner with a 50% overlap; in advanced
practice this can vary.
Brand examples include KoElastic bandage.
High compression bandage.
Not advocated if oedema is present, switch to
an inelastic bandage (Wounds UK2022).
Flex and Profore 4.
Have elastomer bres
making them easily
extensible.
Have less of a
dierence in resting
and working
pressures.
Do not fully occlude
the vein but cause
narrowing.
Elastic is always
present, therefore
pressure is
always present.
Not advocated for the
Can be used in mobile and
management of oedema.
immobile patients.
For the multilayer system a combination of type 3 bandages is selected, dependent on ankle circumference.
Clinical Management ofthe Lower Limb 395
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and 3 bandage categories, therefore bandages outside of these categories are not discussed.
Adjustable Wrap Systems
Wraps consist of a liner underlayer that serves to protect the skin and
an overlayer that is the wrap itself. This is made from a low elastic
material section that wraps across and around the limb and is secured
with hook and loop or Velcro® fasteners. They are designed for selfapplication or in partnership with the practitioner and are therefore
well suited to self- care and shared care approaches. They are available in dierent sizes and thus education is necessary for the practitioner to ensure correct measurements. Wraps are available for
dierent areas of the lower limb including foot, calf, knee and thigh
pieces (Ritchie and Freeman2018). There is also a variety of materials available for dierent uses. The Velcro wrap systems signicantly
reduce the limb circumference and improve the tissue density, which
can be particularly helpful in challenging brosed tissues. A combination of wraps can be used to support the lower limb, for example
foot and calf. Wraps can also be used in conjunction with other therapies, for example a compression bandage could be used to manage
the gaiter ulceration and a knee wrap above may provide treatment
for a swollen knee (Ritchie and Freeman2018).
Whichever tool has been selected, it is important to monitor the
eectiveness of the intervention to ensure that the patient heals.
Table8.17 details how to monitor if the therapy is working.
TABLE8.17
Oedema Wounds
An aim of treatment for swollen lower
limbs should be a reduction in
swelling leading to a normal limb
size and shape.
This can be monitored through
observing for the presence of
guttering (Hopkins and
Worboys2005).
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Monitoring whether therapy is working.
Aim of treatment should be
reduction in wound size leading
to healing.
This can be monitored through
photography and measuring the
wound (Wounds UK2022).
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LOCATION OFTHE ULCERATION
The location of a wound frequently brings its own challenges for
healing. Within the wider context of the body, wounds for example
on the sacrum may be complex due to the risk of cross- contamination
with body uids. The scalp brings its own challenges due to a thin
layer of dermis and hypodermis and the presence of hair. Leg ulceration is no dierent: a wound on the leg will often be harder to heal
than a wound on the arm, purely due to the dierent eects of gravity on the arm compared to the leg. The exact location of the ulceration on the lower limb adds to this complexity. In particular wounds
in the retro malleolar area can be dicult to heal. The reason is that
for many patients the retro malleolar fossa is deep, and even when
eective high compression therapy is applied a ‘hammocking’ eect
can occur, where the ulceration sits deeper within the fossa and so
receives little if any compression. In cases such as this more advanced
techniques such as fan strapping may be required (Hopkins
et al. 2011). These techniques go beyond standard practice and
require additional training. If people are identied as not healing
and they have ulceration in this area, then referral for bespoke or
specialist intervention is needed.
COMPRESSION OFTHE FOOT
A myth exists that the foot should not be compressed. This myth
requires challenge and comparison if practitioners are fearful. The
comparison is that the foot is compressed in leg ulcer hosiery kits, the
foot is compressed in compression hosiery stockings, so why would
we not compress the foot when using bandages as a therapy? Indeed,
not encasing and protecting the foot leaves it vulnerable. Pascal’s law
assures us that if eective compression therapy is applied on a uid
(such as a muscle group) in a closed container (fascia muscularis and
compression bandage), there is an equal increase at every other point
in the container (leg) (Schuren and Mohr2010). However, when the
uid is moved out of the area where compression is applied, there
can be a risk to that tissue if not managed as the uid is shunted
thereby the compression. This can be the foot, the toes or the knee,
so these surrounding areas require protection through skilled
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Clinical Management ofthe Lower Limb 397
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compression. Compression to the foot also augments the foot muscle
pump and can improve walking (see Chapter4).
INTERMITTENT PNEUMATIC COMPRESSION
Intermittent pneumatic compression (IPC) is a mechanical device
that can be used to aid in the healing of several types of ulcers, including venous leg ulcers (Nelson etal.2014), and can help reduce oedema
in patients with lymphoedema (Desai and Shao2020). See Table8.18
for the types of ulceration that an IPC device may be suitable for.
When applied to the lower limb or thigh (depending on which
device is used), IPC comes with a sleeve or cu that is attached to a
motorised machine. The sleeve/cu has cycles of ination and deation that vary in time depending on the device used. An IPC device
comes in a variety of dierent cus/sleeves ranging from foot, below
knee and up to the thigh. In recent years advances in IPC technology
mean that the device can be applied to targeted areas of the body.
This is an advantage for patients who have lower limb ulceration, as
the device can be applied and used without squeezing over the site of
pain and ulceration. For example, even if the venous leg ulcer is
located on the lower leg below the knee, the application of the IPC
device on the thigh is still therapeutic (Partsch etal.2002).
IPC encourages circulation by decreasing venous stasis and
improving arterial ow, improving microcirculation and lymphatic
drainage and reducing the production of inammatory mediators
TABLE8.18
intermittent pneumatic compression may besuitable.
Venous leg ulceration
Mixed aetiology leg ulceration
Arterial leg ulceration
Lower limb pressure ulceration
Diabetic foot ulceration
Lymphoedema
Pyoderma gangrenosum
Sickle cell disease induced ulceration
Source: Adapted from Young etal. (2021).
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Types ofulceration forwhich
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TABLE8.19
compression (IPC) therapy.
Indications Contraindications
As an adjunct therapy to the
application of compression therapy
Painful wound(s) Suspected deep vein thrombosis
Unable to tolerate optimal
compression dose (note that IPC
can be considered, but it is
important to explore and address
the reasons the therapy is
dicult to tolerate and attempt
to address this with the person)
Hard-
to- heal wounds Renal failure
Source: Adapted from Young etal. (2021).
Indications andcontraindications forintermittent pneumatic
Signs of acute infection to the limb
or sepsis symptoms
Suspected or conrmed skin cancer
Acute or chronic limb-
threatening ischaemia
(Young etal.2021). Naik etal. (2019) also highlight the biomechanical eects of IPC therapy, when the endothelial cells release
antithrombotic, pro- brinolytic and vasodilatory properties that aid
in the prevention of clot formation. See Table8.19 for the indications
and contraindications of IPC therapy.
IPC is an adjunct therapy to compression therapy. Optimal dose
compression therapy should always be considered as the mainstay of
treatment in lower limb ulceration. IPC can be used intermittently or
for a set period of time as part of the overall treatment plan, not
instead of compression therapy (Young etal.2021).
WOUND BED PREPARATION AND
CLINICAL MANAGEMENT
While compression is the key to managing most types of lower limb
ulceration, it is also important that appropriate wound bed preparation and dressing selection are undertaken. Chapter5 explained how
to undertake a robust assessment using the TIMES framework. From
this assessment three steps to wound bed preparation are advocated,
which are explained in Table8.20.
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TABLE8.20 Three steps towound bed preparation.
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Regular wound hygiene to
include wound bed
cleansing and
debridement
(Wounds UK2022).
Wash surrounding limb as
discussed earlier in
this chapter.
Cleanse the wound to ensure
removal of debris, exudate
or dressing remnants. This
should include the wound
bed and wound margins.
Undertake mechanical
debridement to physically
remove any
devitalised tissue.
Identication of biolm (IWII2016) and
challenge if present with mechanical
debridement and application of a
topical antimicrobial (Malone
etal.2017; Wounds UK2020).
Key indicators of biolm
presence include:
Recurrence of delayed healing on
cessation of antimicrobial
administration.
Increased exudate levels.
Low- level chronic inammation.
Low- level erythema.
Poor granulation tissue or friable
tissue that bleeds easily.
Hypergranulation.
Wound breakdown and enlargement.
Challenge biolm by undertaking
mechanical debridement at least three
times a week to disrupt the protective
matrix covering the micro- organisms
so that topical antimicrobial can
penetrate to the micro- organisms.
Apply a topical antimicrobial for a
maximum of two weeks, then review.
Application of an appropriate dressing.
Dressings do not heal wounds; the body heals
wounds, given the right nutrition and hydration.
In the case of the lower limb, due to underlying
pathophysiology and the eects of gravity,
compression therapy is key to healing and should
be the key focus, not the type of dressing.
Dressings should be selected for their ability to
provide a contact layer between the leg and the
compression tool being used, to support autolytic
debridement, maintain moisture balance and
manage exudate (see the earlier section of this
chapter for more details on exudate management).
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CONCLUSION
This chapter has examined clinical management, employing a framework that will assess the person, assess the limb and assess the leg.
The overarching aim is to create healing, but it is also important that
other goals such as a personalised approach to care are adopted.
Ensuring the person is left with as good a limb shape as possible is
also a primary consideration, as of course is thinking ahead to the
future and the prevention of ulcer reoccurrence caused by this longterm condition. Chapter 9 will examine the prevention of reoccurrence and the use of compression hosiery stockings.
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