A Guide To Compression Dressings For Venous Ulcers

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

   When it comes to long-term ulcers, clinicians can teach caregivers how to apply short stretch reusable bandages.27 The bandages can be washed per manufacturer recommendations and hung to dry. Replace these bandages every few months. Typically to protect the skin, clinicians use a layer of tube gauze or stockinette over the primary wound dressing.

   The inelastic or short stretch bandages have limited absorptive qualities and may not be optimal in wounds with heavy or excessive drainage. In such cases, the clinician may consider an initial treatment with an Unna boot or multilayer lower compression bandage to manage the heavy drainage, and transition to the inelastic or short stretch bandage after successful exudate management.

   Unna boots are disposable inelastic bandages that have zinc or calamine paste components that may decrease pruritus, dry stasis dermatitis lesions, and help soothe discomfort. One can apply the Unna boot directly over the wound bed or over another primary wound dressing. Then the clinician would secure it with self-adherent cohesive bandaging. This allows for a greater degree of leg conformability as edema decreases. Addition of the elastic outer layer also creates a bandage with a more consistent working pressure and a higher resting pressure.23 Often, it is necessary to apply a middle layer of gauze or cast padding to absorb wound drainage.

What You Should Know About Elastic (Long Stretch) Bandages

The elastic bandages, as their name implies, have high elasticity and are able to stretch up to several times their length. They accommodate the shape of the leg and sustain high pressures during both ambulation and relaxation.5 The table “An Overview Of Compression Products For Venous Ulcers” (above) lists examples of elastic or long stretch bandages.

   This bandage type is recommended for patients who are immobile, have a fixed ankle joint or an inadequate calf pump.16 They are not intended for use in patients with arterial insufficiency. Patients can also reuse and wash these bandages according to the manufacturer recommendations. Several companies make high compression elastic bandages that have rectangular or square markings along the bandage to ensure a constant tension during application. One may need to apply padding to prevent localized areas of excessively high pressure, especially over prominent tibial crests.

   It is important to note that greater elasticity does not always equate to better efficacy. A bandage with too high an elasticity will provide too low a working pressure to facilitate venous flow. This is because the high elasticity will allow the bandage to flex excessively with each leg movement rather than support the calf pump. A bandage with too high an elasticity will also provide a high resting pressure that may vary along the length of the leg. This variation can hinder venous flow due to uneven pressure gradients and potentially be dangerous in the presence of arterial disease.16

   Examples of this type of bandage are those physicians typically use for the management of orthopedic injuries or as surgical dressings such as ACE bandages. ACE wraps are intended for short-term use, not for the treatment of chronic venous insufficiency.

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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