H Charles, PhD, MSc, BSc, RGN, RSCN, NDN, PWT.
Clinical Nurse Specialist, St Charles Family Health Centre, LondonInformation on the following pages is brought to you as a joint initiative between Professional Nurse and the Journal of Wound Care. This will be a regular feature in each issue of Professional Nurse - offering a selection of the latest evidence-based practice in tissue viability. This paper is based on an article first published in Journal of Wound Care, June 1999 (8: 6, 303-304). To subscribe to the Journal of Wound Care, call 01858-438847(£37 personal).
Information on the following pages is brought to you as a joint initiative between Professional Nurse and the Journal of Wound Care. This will be a regular feature in each issue of Professional Nurse - offering a selection of the latest evidence-based practice in tissue viability. This paper is based on an article first published in Journal of Wound Care, June 1999 (8: 6, 303-304). To subscribe to the Journal of Wound Care, call 01858-438847(£37 personal).
There are a number of options for treating venous leg ulcers, including multilayer, long-stretch and intermittent compression. Two short-stretch bandages have also been used effectively in Europe since the 1960s.
The concepts of resting and working pressure have been described by Haid and Hinger (1971) and others (Stemmer et al, 1980; Partsch, 1984; Partsch et al, 1992; Veraart et al, 1997). These can be summarised as follows:
- Resting pressure is the force exerted by the bandage on the leg when the calf muscle is not working. This pressure is produced when the bandage is stretched and applied
- Exercising the calf muscle produces working pressure - an internal force that is directed towards the applied bandage. The difference between resting and working pressure produces a pulsating effect when the muscle is exercised.
Long-stretch and short-stretch bandages
Long-stretch bandages stretch to more than 100% of their original length. They should not be fully stretched during application to allow for expansion when the calf muscle produces working pressure during exercise. The working pressure is reflected back into the leg and also expands the bandage. The bandage is pushed and stretched outwards in a similar way to when a ball hits a net. This means that some of the beneficial calf muscle force is dissipated in stretching the bandage.
Short-stretch bandages are made of cotton and have an extensibility of 70-90% of their original length. For example, a bandage measuring 3.0m can be stretched up to 5.7m. They are applied at full stretch so that when the calf muscle is exercised they do not expand in the same way as a long-stretch bandage. The working force produced by the calf muscle is therefore reflected back into the leg. This can be compared to a ball being hit against a wall and bouncing back. When the short-stretch bandage is applied at full stretch, more of the beneficial calf muscle force is directed back into the leg.
Benefits of short-stretch bandages
Short-stretch bandages offer several advantages (Box 1). A short-stretch compression bandage aids oedema reduction, which reduces leg circumference. If the bandage is not reapplied, however, the effect will be lost.
From clinical experience, leg circumference reductions of up to 3cm in a 24-hour period have been noted. We check for oedema reduction and re-bandage the leg as necessary.
In addition, we have observed a direct relationship between oedema reduction and pain relief. During a recent trial, we monitored 90 patients being treated with short-stretch bandages.
Pain was reduced by more than 50% after two weeks as measured on the visual analogue scale (poster, 1998 Symposium on Advanced Wound Care and the Medical Research Forum on Wound Repair, Miami 1998).
Methods of application
Various methods can be used to apply short-stretch bandages, including the simple spiral technique and the Pütter and Fischer techniques (Heede, 1981; Bischof, 1981; Holan, 1981; Fischer, 1987). Padding should be considered.
Areas of high pressure and sites at high risk of pressure damage must be protected by padding (Figure 1). These include the Achilles tendon, tibia, malleoli, and the dorsum of the foot.
Simple spiral technique
Start applying the bandage at the base of the toes. Follow the leg shape with a spiral rotation, to just below the knee. The bandage should be held as close to the leg as possible, giving more constant pressure.
The Fischer technique
The Fischer technique is used to apply inelastic paste bandage. Application starts at the heel, proceeds to the base of the toes, and is then applied in a spiral rotation, following the shape of the leg to just below the knee. Compression measurements of 40mmHg in the resting phase and 60mmHg in the working phase have been recorded (Haid and Hinger, 1971).
The Pütter technique
This technique uses two bandages. The first is applied from the malleolus to the base of the toes, then in a spiral rotation up the leg. The second is applied starting at the malleolus and, reversing the direction of the first spiral, in rotation to the base of the toes and then up again. The bandage can then be secured with tape at the end, and at other points of stress such as the heel and ankle.
St Charles Leg Ulcer Clinic bandaging technique
We have found that, for legs with a 'champagne-bottle' shape, or those with an ankle circumference greater than 25cm, bandages applied with the simple spiral technique do not stay in place as well as those applied with a modification of the Pütter technique (Figure 1), now known as the St Charles Leg Ulcer Clinic bandaging technique. The bandage starts at the malleolus and is then rolled down to the base of the toes. From the toes, it is rolled upwards following the leg's shape. It is then 'anchored' with a circumferential turn below the knee and rolled down again without tension, finishing about mid-calf. The leg below the knee is fully bandaged.
We have used the spiral and modified Pütter techniques for mobile and housebound patients with good results. In the most recent audit, the district nursing service achieved a healing rate of 59% for venous leg ulcers in a three-month period; in the clinical setting the figure was 81% (Charles, 1996). Other trials report healing rates of 50% or more over three months (Charles, 1991; Travers et al, 1992; Partsch and Horakova, 1994; Stacey et al, 1995).
The effectiveness of short-stretch bandaging as a treatment to control oedema, reduce pain and promote venous ulcer repair is well documented. Short-stretch bandaging is also cost-effective and encourages patient compliance.
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