Brenda King, MSc, BSc, RGN, is clinical nurse specialist, tissue viability, Sheffield PCT.
King, B. (2007) Toe bandaging to prevent and manage oedema. Nursing Times; 103: 43, 44–47.
Toe oedema is more commonly associated with lymphoedema but is frequently seen in patients with venous hypertension. In the long term it leads to toe deformity and it is essential that the problem is managed. Brenda King outlines how to apply toe bandages and the long-term management once the problem is resolved.
Oedema and lymphoedema are the terms used to describe an abnormal accumulation of fluid in the interstitial spaces (Silverthorn, 1998). Lower-leg oedema forms for a variety of reasons (King, 2006) and needs to be appropriately managed. However, it frequently extends into the feet and toes and is often ignored or badly managed.
With lymphoedema a relatively protein-rich fluid results from dysfunction of the normal flow of lymph fluid. In the early stages it is known as simple oedema: the area may be soft and pits easily with finger pressure and may improve when, for example, the affected limb is elevated. However, without treatment the condition progresses and in longstanding lymphoedema the accumulation of excessive interstitial fluid is accompanied by fibrous tissue and fat deposits. Lymphoedema of the leg is managed by bandaging the leg and toes (Todd, 2000) during the intensive phase of treatment.
Toe bandaging is not routinely used for patients with venous hypertension, possibly because the definition of venous hypertension is restricted to the gaiter region (Altenkamper and Eldenburg, 1993). However, patients with venous hypertension may experience oedema of the forefoot and toes, especially when the underlying problem is poorly managed. They may also experience problems with lymphovenous oedema and gross gravitational oedema. Toe bandaging may be indicated but is rarely carried out. A possible reason for this is that nurses are not routinely taught toe bandaging.
Conditions such as protein deficiency or cardiac failure may lead to leg and toe oedema and it is important that underlying contributing factors are identified and treated (Green and Mason, 2006).
Toe and forefoot oedema can also develop when compression bandages are applied if the patient’s calf circumference is small compared with the ankle circumference – for example if it is only equal to, or a few centimetres more, than the ankle. In this situation, if a long-stretch elastic compression bandage is applied, an adequate reduction in sub-bandage pressure to reverse venous hypertension will not be achieved. To avoid this, it is important to increase the calf circumference by adding additional padding from the wool layer of the bandage system.
Multi-layer bandage systems involve applying layers of bandages over the front of the ankle, which may increase pressure in this area. If insufficient bandage turns and support are applied around the forefoot, the increased pressure over the front of the ankle may trap fluid in the toes. These then become oedematous and are gradually deformed with lymphoedema changes. Problems can also occur with other types of bandages.
Managing oedema with toe bandaging
Preventing forefoot and toe oedema and deformed toes can be achieved by toe bandaging, but, anecdotally, nurses appear apprehensive about the technique. It may be relatively simple but education, training and competency is essential as any bandage applied inappropriately around digits or limbs may cause trauma.
It is crucial to select the correct product. Some compression bandages that apply high levels of sub-bandage pressure are available in a narrow width but these should not be used for toe bandaging as they may easily cause skin damage.
Several types of lightweight conforming bandages available on the drug tariff in the community can be used for toe bandaging. The smallest width listed on the tariff is 5cm and some practitioners use this but occasionally it is too big for the smaller toes, even when folded. Bandages, such as Mollelast, are 4cm wide and available specifically for toe bandaging (not available on the drug tariff).
- It is advisable to fill out any creases, crevices or fissures in the skin with foam before bandaging in order to prevent skin damage (Todd, 2000).
- The bandage starts around the forefoot and is applied from inside to outside (Fig 1) – this ensures a good bandage position for the great toe.
- The first turn of the bandage on each toe is at the distal end then the bandage is applied towards the proximal end of the toe (Fig 2), maintaining tension but not stretching the bandage. The number of turns depends on the size and condition of the toe.
- The bandage may need to be folded for smaller toes, affecting how many turns are applied.
- After each toe is bandaged, the bandage is taken around the foot to secure it.
- It is not always necessary or possible to bandage the smallest toe (usually the least affected).
Frequency of bandage change
If toe bandaging is being used for prevention, the toe bandage should be changed at the same time as the bandage/compression system on the leg. If the toes are already oedematous it is advisable, initially, to change the toe bandage more often as the oedema reduces to achieve optimum toe shape. This may be necessary daily for the first few days.
Once the desired reduction in oedema and shape has been achieved it may be possible to measure and fit a toe garment (toe gloves) (Fig 3) for long-term management. However, bandaging must be maintained until this is available. These garments can be used with compression bandages but are not available on the drug tariff and must be purchased.
Patients may also have skin problems that will not be addressed by bandaging alone. Oedema can lead to a deterioration in general skin condition due to ineffective capillary dynamics (Silverthorn, 1998). One consequence of this is hyperkeratosis, a build-up of skin scales on the surface, which takes on a warty appearance. Failure to manage this will allow the build-up of the hard, dry, dead skin. Meticulous attention to skin care is vital, including daily inspection, hygiene and application of emollients. This is important to reduce the risk of cellulitis, which is common in oedematous tissue.
The development of forefoot and toe oedema can lead to many problems, not least skin breakdown and ulceration. It also affects patients’ quality of life as they may be unable to wear normal footwear.
Altenkamper, H., Eldenburg, M. (1993) A Colour Atlas of Venous Disease. London: Manson Publishing.
Green, T., Mason, W. (2006) Chronic oedemas: identification and referral pathways. British Journal of Nursing; 11: S8–S16.
King, B. (2006) Diagnosis and management of lymphoedema. Nursing Times; 102: 13, 47.
Silverthorn, D. (1998) Blood flow and the control of blood pressure. In: Human Physiology: An Integral Approach. Upper Saddle River, NJ: Prentice Hall.
Todd, J. (2000) Containment in the management of lymphoedema. In: Twycross, R. et al (eds). Lymphoedema. Abingdon: Radcliffe Medical Press.