A Guide To Compression Dressings For Venous Ulcers

Author(s): 
Nancy Slone-Rivera, MS, ANP-C, CWON, CFCN, and Stephanie C. Wu, DPM, MSc

Pertinent Insights On Compression Products

One can divide compression products into different categories: elastic versus inelastic; short versus long stretch; high compression versus mild versus low; single- versus multi-layer; and stockings versus bandages versus pumps. The products vary in their actions and pressures, but are generally classified based on the level of compression provided at the ankle.15 Several guidelines offer recommendations for the treatment of venous insufficiency.4 In theory, the goal compression for a patient without arterial disease should approach 40 mmHg at the ankle. With decreased ankle-brachial indices, less pressure is recommended.16

   To achieve a graduated compression gradient, one needs to apply a bandage at a consistent tension and the bandage should be able to retain its shape over a long period of time. The pressure exerted on a limb is directly related to the number of layers one applies, the tension of application and is inversely related to the circumference of the limb and the width of the bandage.17 In other words, the more layers and the higher the tension, the higher the pressure. The smaller the limb and the narrower the bandage, the higher the pressure.

   When clinicians apply a compression bandage to a normally shaped leg, the narrower ankle, when wrapped with the same bandage at the same tension with a consistent 50 percent overlap, will have a higher sub-bandage pressure than the wider thigh. Accordingly, this provides a graduated compression and improving venous return.
Practitioner technique can also affect the sub-bandage pressure.5 Skilled instruction is recommended prior to introducing these techniques into clinical practice.

What The Research Reveals About Inelastic (Short Stretch) Bandages

Inelastic bandages, also known as short stretch bandages, have minimal stretch and can only extend up to 30 to 70 percent of their length.18 Examples of inelastic bandages are included in the table “An Overview Of Compression Products For Venous Ulcers” at left. Patients can launder and reuse many of these bandages. Inelastic bandages provide compression not so much in the bandage itself but as a firm barrier against which the calf muscle presses during ambulation, thus supporting calf pump action.16

   The inelasticity offers a high working pressure (30 to 40 mmHg) during ambulation and a low resting pressure when the leg is inactive or supine.19 This property may allow safer use when the patient has a venous ulcer in combination with decreased arterial circulation.16 One small study demonstrated safe and effective venous ulcer treatment with short stretch bandaging in 24 patients with a mean ankle-brachial index (ABI) of 0.62.20 These bandages may not be the best choices for patients with inadequate calf pumps such as those with limited ankle mobility, abnormal gait patterns, paralysis, immobility, and muscle wasting diseases that result in lower extremity muscle atrophy.5,21,22

   The recommended application for inelastic bandages is a spiral wrap from the base of the toes to two fingerbreadths below the patella with a 50 percent overlap, consistent tension and avoidance of wrinkles and folds.

   Clinicians may employ short stretch bandages to decrease edema. However, they are unable to sustain consistent compression for prolonged periods of time.23 The inelastic characteristics of these types of bandages do not allow for contouring of the bandage to the leg circumference once the edema has decreased. This can lead to slippage and creases in the bandage that can cause skin breakdown and discomfort.24 Therefore, one may need to change inelastic bandages more frequently until edema reduction has reached a steady state.16,25

   The literature suggests that short stretch bandaging is as effective as any other compression bandage at reducing edema. However, short stretch bandaging may not be as effective at healing ulcerations.26

Comments

As a disclosure, I am VP of Farrow Medical, which manufactures short stretch garments. This is a long comment.

I would like to clarify a point with regard to the definitions herein of inelastic versus short stretch, which I believe, as stated, allow for confusion, even historically, predating 2006.

I don't believe inelastic products are historically considered to be products with 30 to 70% stretch. In fact, Foldi specifically distinguishes between short stretch and inelastic.

Why would they be separated in textbooks and yet be referred to by others as the same or similar?

If a product with less than 15% stretch, as an example, is applied, there are several issues.
1. You are not really sure how much compression is being applied because the amount of compression is directly related to how hard the provider is pulling. Does the provider know how hard he is he is pulling? Does the next person applying know how hard he or she is pulling?
2. Products with this amount of stretch don't work terribly well over joints, such as the anterior ankle, and this can cause ulcerations.
3. True inelastic products are generally reserved in wound centers for patients with a low AB index, and they are applied with very little tension, meaning they are applying little if any significant resting compression. They depend upon a higher working compression to reduce/control edema.
4. If the leg decreases significantly in circumference as a result of higher working compression levels generated, the garment can slide down and the higher working compression advantage would be lost until readjusted.

"Short stretch" products are applied with some stretch and hence, inherent in that stretch is some tension, which translates into ~some~ compression. As the authors appropriately state, this compression level can fall of rather abruptly with time. Short stretch bandages, traditionally, are manufactured of 100% cotton and depend a good degree on the weave of the product to produce the tension and hence compression. So if a product which has some stretch but little sustained elastic compression of its own is applied near its maximal stretch, it would essentially function as inelastic, although if the leg reduced in size, it "might" shrink along with the leg, but also provide a lower working compression level.

If, however, a product with short (limited or low) stretch AND elastic fibers was used, the compression would not fall off as quickly and the performance would be hybridized with other elastic compression garments. By hybridized, I mean provide a steady lower resting compression (like a stocking) AND a higher working compression (more like inelastic).

Why is this important?

In my opinion, with elastic short stretch products ...
1. The short stretch can better cue you in to the amount of tension being applied by feeling the abruptness of the short stretch and hence the tension level.
2. The stretch allows for better functionality over joints.
3. The short stretch generally allows for more consistent low resting compression and higher working compression levels (working like a pump when the patient ambulates when properly applied). (It is sometimes referred to as a poor man's pump.)
4. The product can shrink some if the leg decreases in size, limiting slippage and the need for adjustments.

As a clinical example, in a chair-bound nursing home resident, a truly inelastic product that is properly applied might apply very little resting compression (or if too tight could be a tourniquet). A short stretch product with elastic fibers would apply some sustained resting compression with the potential for higher working compression when properly applied. Long stretch wraps have the potential to produce highest sustained resting compressions, which can be a little more hazardous if not professionally applied, and lower working compressions unless applied with a significant (potentially more dangerous) amount of tension.

Conversely, if a patient had poor arterial circulation, the provider may opt to apply a product that is "inelastic" with very little tension applied because a lower resting compression has a lower potential to block arterial circulation, but still has the potential to provide a higher working compression to help reduce/control edema. Note that this would work best if the calf muscle pump was functional.

One last point. A product that is inelastic applied and just barely snug would apply a low resting compression when vertical, but very little, if any, when lying down. Short stretch would apply more resting compression than inelastic when lying down. Long stretch would generally provide the most compression when lying down (and the least potential for high working compression when vertical). So patients with impaired arterial circulation are generally safer with inelastic, then short stretch products, when they lie down, as opposed to long stretch, IF compression is safe be applied at all depending on the situation.

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