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TABLE8.11 Laplace’s law explained.
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What does it mean? Hints and tips
How pressure
(dose) is aected
T Tension How tightly or loosely
the compression
therapy is applied
can aect the
amount of pressure
(or dose) applied.
N Number
of layers
applied
C Circumference
of the limb
W Width of
the bandage
Source: Adapted from Clark (2003) and Charles (2012).
The number of layers
applied will aect
the pressure.
The more layers the
more pressure,
therefore the
higher the dose.
The higher the
circumference of the
limb, the lower the
pressure or dose of
the compression.
The narrower the
bandage, the higher
the pressure applied.
Tension is particularly important when applying a wrap or bandage.
When applying a bandage, the practitioner should apply it with
consistent pressure and stretch as they apply the bandage from the
base of the toe towards the thigh (distal to proximal). This will create
graduated compression therapy and move the uid from the peripheral
towards the central circulatory system.
Some bandages are applied at ‘full stretch’, some at less, such as ‘50%
stretch’. Ensure you understand the instructions for the system you
are using.
This is important for bandages as bandages applied in a spiral will create
two layers, bandages applied in a gure of eight will create three layers.
For other forms of compression such as compression hosiery stockings,
this is important as practitioners can add layers of hosiery to achieve
the required dose.
In some systems such as inelastic bandages, additional layers can also
create stiness, which is useful when eectively encasing the limb.
A larger limb circumference will receive less pressure. This is particularly
important when managing large oedematous limbs where the pressure
will be reduced. Similarly, small thin limbs will be subject to higher
levels of pressure.
Pressure exerted is
directly
proportional.
Inversely
proportional.
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Clinical Management ofthe Lower Limb 383
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TABLE8.12
lower limb.
Reduces inammatory mediators such as matrix metalloproteinases and
cytokines.
Reduces oedema/swelling, part of the unwanted inammatory response.
Reverses venous hypertension.
Source: Adapted from Partsch and Mortimer (2015).
How compression reduces theinammatory response inthe
Wounds that are hard to heal have frequently become ‘trapped’
in the inammatory phase of wound healing, leading from the normal sequence of phases in wound healing discussed earlier in the
chapter to an extended period of inammation, causing what is
termed ‘chronicity’. These wounds will benet from the antiinammatory action of compression therapy. However, the antiinammatory eects of compression are important even before the
occurrence of a wound. Symptoms such as venous skin changes and
swelling can be attributed to the underlying inammatory responses
that are occurring in the lower limb due to venous hypertension raising enzymes such as matrix metalloproteinases and cytokines within
the tissues. Thus, the symptoms of irritation that are visible on the
skin’s surface are due to underlying inammation that can be
reversed with compression therapy. Classic examples of these include
venous eczema, oedema, lipodermatosclerosis, itching, aching and
heaviness, all of which are signs of venous disease that can occur
before the ulceration itself happens. These are listed in Table8.13
and there is more about how to assess each of these signs in Chapter5.
It is also important to recognise that wounds and legs that have
become hard to heal often have higher than normal levels of colonisation by micro-
organisms, which may manifest as biolms, acute
TABLE8.13 Signs ofinammation
before ulceration may have occurred.
Aching and heaviness
Itching
Venous eczema
Oedema and swelling
Lipodermatosclerosis
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infection or both. Micro- organisms thrive in environments where the
wound has become overly wet, and excessive exudate is triggered in
part by inammation, so again, in combination with cleaning,
debridement and the appropriate use of antimicrobial therapies (discussed later in this chapter), using compression to reverse the underlying inammation and thus oedema is key. Importantly for the
person with ulceration, reducing inammation will also reduce their
pain; it is this knowledge that can underpin condence in commencing compression therapy.
CAUTIONS ANDCONTRAINDICATIONS
Compression therapy is contraindicated, or should be used with caution, for some patients. Look back to Table8.6 for an overview.
Presence ofPeripheral Arterial Disease
Compression therapy in the presence of peripheral arterial disease
can be further sub- divided into patients who have a mixed aetiology
limb and patients who present with critical limb- threatening ischaemia; a signicantly dierent approach to clinical management is
required for each. As discussed in Chapter5, the use of compression
therapy is not wholly excluded in those who have arterial disease and
it may be used with caution, applying a lower dose in those patients
with a mixed aetiology of venous ulceration and presence of some
arterial occlusions (Partsch and Mortimer2015). However, in order
to ensure arterial inow is not reduced, compression pressure should
never exceed the local arterial perfusion pressure. This is why we
consider absolute values of the ankle pressure, in addition to the
ankle brachial pressure index (ABPI). Therefore, a systolic ankle
pressure of 50 mmHg or less is a strict contraindication against compression therapy (Partsch and Mortimer 2015) and compression
should not be applied in those who have an absolute pressure of less
than 60 mmHg due to the presence of signicant peripheral arterial
disease. For patients presenting with these values or if visual signs of
critical ischaemia are observed, then an urgent referral to the local
vascular service using local pathways is required without delay.
The decision to recommend a lower dose of compression therapy
for patients who have mixed aetiology ulceration, or in the presence
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of some peripheral arterial disease, should only be undertaken by clinicians who possess knowledge and skills in this area of lower limb
management (Ritchie and Taylor 2018). Thus for many clinicians,
referral to a senior colleague or specialist is advised if arterial involvement is identied through the holistic clinical assessment.
Presence ofDeep Vein Thrombosis
The approach to compression therapy in the presence of DVT can be
sub- divided into those who are already wearing compression therapy
and those who will require compression therapy due to the damage
that occurs to the venous system as a result of the DVT, in order to
prevent future lower limb problems. If patients diagnosed with DVT
are not wearing compression, it is safe to apply compression once anticoagulation treatment has been commenced. There is no evidence at
present to suggest that risk of pulmonary embolism is increased as a
result of appropriately applied compression therapy (British Lymphology Society 2021). If the patient is already wearing compression
hosiery when a suspected DVT occurs, a same- day assessment and
scan (within 24 hours) are required. Therefore, it is important to follow
the local pathway to arrange referral for this. Compression therapy
should be paused as soon DVT is suspected, and should be removed
until the absence or presence of DVT is conrmed. When the diagnosis is conrmed and anticoagulant therapy has started, compression
hosiery can be reapplied, but only if the person can tolerate it; during
the acute stage it may be too painful to begin with and so consideration
of analgesia is necessary. It is also necessary to ensure a full reassessment, as the DVT may cause volume changes to oedema in the limb,
skin changes or possible breakdown of skin integrity (BLS2021). For
practitioners not familiar with compression therapy in the presence or
suspected presence of a DVT, escalation to a senior or more experienced colleague for support to maintain patient safety is recommended.
Important Co- morbidities
Other co- morbidities that require a cautious approach to compression include patients who have chronic heart failure, renal impairment, diabetes and patients receiving end- of- life or palliative care. It
is important to note that the application of compression therapy
should not be ruled out, and a high number of patients with these
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conditions will certainly need compression therapy, but an awareness of how their other co- morbidities will aect their lower limb
management is important to ensure eective clinical therapy.
Compression inHeart Failure
There is a reluctance to apply compression therapy for people who have
a diagnosis of heart failure. This is understandable and requires exploration, as frequently the practitioner will be presented with a dichotomy
of solutions and challenges in the face of this type of complexity. First,
heart failure should be sub- divided into stable or unstable heart failure.
Those whose health and condition are unstable require support from
the MDT to manage the heart failure in the rst instance. For those who
have stable heart failure, challenges are also present, but carefully managed compression is advocated. Not to act and treat the person’s leg
ulceration, oedema or lymphorrhoea constitutes an omission in care. It
is not safer or kinder to leave this person with unmanaged lower limb
problems, and indeed this places them at risk of further deterioration in
their ulceration, infections, sepsis and even death, so not acting is not an
option. However, it is acknowledged that fear and lack of knowledge
exist in this area at a standard level of practice. Therefore, it is suggested
that patients who present with lower limb ill- health and stable heart
failure are referred urgently to specialist services such as tissue viability,
where measured but progressive compression in heart failure can be
instigated and monitored as part of the MDT.
CONSIDERING ANDCOMMENCING TREATMENT
Once aetiology and an accurate diagnosis are established, and any
contraindications or cautions explored, if compression therapy is
indicated it is then important to select the correct mode of therapy,
for example a particular bandage system or wrap from the selection
of tools in the toolbox (see Table8.1).
Compression Hosiery Kits
Compression hosiery kits, sometimes referred to as leg ulcer hosiery
kits, are designed to deliver graduated compression therapy to support venous return. They should not be confused with single- layer
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hosiery stockings. Compression hosiery kits consist of two stockings,
an understocking and an overstocking, which together should oer a
dose of at least 40
ankle circumference of 18–25 cm, as well as stiness that is achieved
through the combination of two layers that would not be achieved
through a single stocking alone (Ritchie and Freeman2018).
Dierent products and brands oer dierences in dose for the
understocking and overstocking, for example in some kits the understocking delivers approximately 20 mmHg and the overstocking
20 mmHg, totalling an overall dose of 40 mmHg; other brands oer
an understocking of approximately 10 mmHg and an overstocking of
25–35 mmHg, again totalling 40 mmHg.
Compression hosiery kits can be considered as rst- line treatment for venous leg ulcers that are not complex in nature, for example in people who have a small ulceration, who have a normal- shaped
limb and are not experiencing high levels of exudate. People with
high volumes of exudate, the presence of deep skin folds or distortion
due to established oedema or a very oedematous limb should be
excluded from treatment with compression hosiery kits. The advantages and limitations of compression hosiery kits are highlighted in
Table8.14.
mmHg at the ankle in people who present with an
Bandages
A variety of bandages are available. It is important to understand
how these dierent bandage systems work and how the dose or pressure is achieved. Regardless of the type of bandage to be used, it is
important rst to measure the circumference of the ankle just above
the malleolus. Within UK clinical practice boundaries regarding
ankle circumference are advocated to inform how the practitioner
should choose and apply a system, because ankle circumference is
normally an indicator of overall leg size and this can aect the dose,
as discussed earlier within the framework of Laplace’s law. See
Table8.15 for further discussion on this. It is also important to note
that very tall people, those >180 cm tall (Wounds UK 2022), frequently need higher levels of compression, and often so do people
who have a particularly long limb length between the malleolus and
the knee; this is due to the increased eects of gravity on the lower
limb. This is not explored here, but be aware that if despite the
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TABLE8.14 Advantages ofcompression hosiery kits.
Health
service outcomes
Possible reduction
in costs when
used
appropriately.
Clinical time can
be reduced in
terms of
frequency of
consultations
and shorter
appointments
(Tickle2015).
A consistent
compression
dose is given,
which is not
aected by
practitioner skill
or competence
(Tickle2015).
Training in this
type of therapy is
less complex
than for some
other treatments.
Personcentred benets Other considerations
Can be used in
Kits may also be more
People may become
care, shared care
selfwith the health
professional and
with carer or
family support.
acceptable, as they
do not interfere with
shoes or clothes,
they are more
discreet and this
may make the
treatment easier
to tolerate.
accustomed to
compression hosiery
kits and may
associate this with
healing, thus they
may be more willing
to wear similar
therapies in the long
term such as hosiery
to prevent
reoccurrence.
Compression hosiery kits
are not suitable for all
patients, as fragile skin
can be damaged when
putting them on or
taking them o, and
some people are
unable to do this at all
due to compromised
exibility or impaired
dexterity. It is
important to assess
this aspect.
More agile patients can
remove compression
hosiery kits, whereas a
bandage is more telling
if it has been adjusted
or tampered with.
Donning and dong
devices are available
and prescribable via
the NHS and so
practitioners should
always consider if
these should be
supplied in
combination with
compression
hosiery kits.
Source: Adapted from Ritchie and Freeman (2018).
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TABLE8.15 Ankle circumference.
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Circumference Size Bandaging Cautions Advice
<18 cm Regarded as a
small ankle.
18–25 cm Frequently
viewed
as a normal
ankle.
>25 cm Recognised
asa
large ankle.
Bandage carefully and
consistently.
Bandage consistently. Ensure a wadding layer is
Consider additional layers
and using a short
stretch inelastic system,
as it is most likely that
oedema will be present.
Ensure a wadding layer is
used to protect the bony
prominences, but do
not over- pad.
used to protect the bony
prominences.
Be careful not to over- use
a wadding layer.
Think Laplace–
remember the
pressure is higher on
a smaller limb
circumference.
Think Laplace–
remember the
pressure will be
lower on a larger
limb circumference.
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correct dose and application of compression a person is not healing
and they are very tall or have a long lower leg, you should consider a
referral to specialist services for more advanced techniques (Hopkins
etal.2017).
Once the ankle is measured and routine hygiene and skincare
are completed (steps in eective skin care are discussed earlier in this
chapter), the next step is to add in a simple protective layer under the
wadding layer to protect the skin from irritation that can be caused
by the wadding layer. This should be a knitted tubular stockinette
(Figure8.9), which should be applied from the base of the toe to just
above where the bandage will stop. It is advisable to leave a few centimetres extra at each end so that this may be rolled back over the
outside of the compression bandages once applied.
Next is the wadding layer. This is not a bandage and does not
apply any compression or pressure. The purpose of the wadding layer
is to protect bony prominences, which are subject to a higher interface pressure and are therefore more vulnerable to pressure that may
cause discomfort. Beware of overciency of the compression bandages, as explained by Laplace’s law.
Normally one roll is enough, and in occasional circumstances two.
See Figure8.10 for the wadding layer and how it is applied eectively.
padding, as this will aect the e-
FIGURE8.9 Tubular stockinette.
Source: Courtesy of L&R.
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FIGURE8.10 The wadding layer is applied to protect the bony
prominences on the dorsum of the foot.
Source: Courtesy of L&R.
FIGURE8.11 The wadding layer.
Source: Courtesy of L&R.
Next the wadding layer is applied in a spiral application, overlap-
ping by approximately 50% on each turn around the leg (Figure8.11).
Following the wadding layer, the compression bandages can be
applied. Table8.16 subdivides the dierent types of bandages and
the variety of terminology used, which can lead to confusion for
the novice practitioner. Names such as ‘two- layer’ and ‘four- layer’
are not advocated. Compression bandages fall within the type 2
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