leg ulcer management in patients with chronic oedema - Wounds ...

ReviewLEG ULCER MANAGEMENT INPATIENTS WITH CHRONIC OEDEMAChronic oedema is a long-term condition as its title suggests. It causes disruption to patients’ livesand can be costly to treat if managed inappropriately. Leg ulcers in patients with chronic oedemaoccur more frequently than acknowledged by many healthcare professionals. This client grouprequires a specifi c management plan if the oedema is to be controlled and the ulceration healed.Tracy Green isa MacmillanLymphoedemaClinical NurseSpecialist, Calderdale& Huddersfield NHSFoundation TrustLymphoedema is a chronic(long-term) condition, that is alsoreferred to as chronic oedema. Itis characterised by swelling of anypart of the body resulting fromfailure of the lymphatic system. Itis often thought of as a sequel tocancer treatment, predominantlyin breast cancer patients (Armeret al, 2004; Stanton et al, 2006).However, a study carried out in aLondon primary care trust (PCT)concluded that chronic oedemais as common as leg ulceration,with a crude prevalence of 1.33per 100,000 people, rising toone per 200 people over theage of 65 years (Moffatt et al,2003). Furthermore, the studyidentifi ed that more than half ofall patients were suffering fromchronic oedema associated withpoor venous function (also knownas lymphovenous oedema) andprimary lymphoedema.The study also highlighted thata number of patients were notreceiving adequate treatment.This appeared to be due to theprovision of services for cancerrelatedlymphoedema but poorlyFigure 1. Ulceration can follow a superficial infection in the oedematous limb(Courtesy of St. Giles Hospice).provided care for patients withnon-cancer related lymphoedema(Moffatt et al, 2003).A further study by Morgan etal (2005) assessed communitynurses’ knowledge and skill in thecare and management of patientswith lymphoedema as adequateor poor. It was found thatcommunity nurses were uncertainof their role in conjunction withother professions caring for thispatient group.Although chronic oedema isnot directly responsible forulcer development, it will affectwound healing (Mortimer andBrowse, 2003). This is due tothe reduced oxygenation ofthe tissues resulting from thepresence of oedema (Casley-Smith and Casley-Smith, 1997).As such, skin damage to anoedematous limb may leadto ulceration. Ulceration canalso follow superfi cial infection(Figure 1).Approximately 70% of leg ulcersare caused by venous disease(Callum, 1992). The underlyingcause is venous hypertension,which can with time result inchronic oedema. It is therefore46 Wound Essentials • Volume 2 • 2007

Reviewlikely that patients with co-existingoedema and leg ulcers, eitheras a result of trauma or venousdisease, will be encounteredfrequently in practice.This article aims to promoterecognition of chronic oedemaand lymphoedema in patientswith leg ulceration, and willdiscuss what implications thediagnosis of chronic oedema willhave on the management of thepatient with leg ulcers.The lymphatic systemThe lymphatic system has animportant role in maintainingfluid balance. It carries fluid, fatsand proteins back to the generalcirculation from the tissues thatwould otherwise accumulateas oedema. It also providesan important immunologicalfunction (Levick and Mortimer,2003), carrying immune cellssuch as lymphocytes andmacrophages to the lymphnodes (Mortimer, 2000).Circulating blood carries fluidand nutrients to the bodytissues. As blood passesthrough the capillaries, fluidleaks out through the semipermeablewalls (filtration) andinto the interstitial space thatlies between the capillary walland the tissues.The exchange of nutrients,wastes, fluid, electrolytes, andproteins from the vascular andlymphatic systems and tissuecells occurs through this space.In this area, pressure may below and attract fluid into thetissue, or an increase in tissuepressure forces fluid into theinitial lymphatics and capillaries.It is in the interstitial fluid spacethat the forces resulting inoedema come into effect.Evidence has shown that themajority of interstitial fluid isreturned to the blood circulationvia the lymphatic system andnot, as initially thought, byabsorption directly into venouscapillaries (Mortimer andLevick, 2004). The absorptionof interstitial fluid is the crucialrole of the lymphatic system inmaintaining fluid balance. Whenthe lymphatic system is unableto maintain this role, oedemaoccurs.LymphoedemaLymphoedema is defined asswelling of a limb or part ofthe body due to failure of thelymphatic system. It resultsprimarily when the lymphdrainage system fails toadequately drain fluid from theinterstitial spaces. This failureleads to an accumulation offluid and proteins in the tissues,resulting in swelling or oedema.It can affect any part of the bodybut usually affects the limbs and/or the adjacent quadrant of thebody (Board and Harlow, 2002).Lymphoedema is classified asprimary or secondary. Primarylymphoedema is due to anintrinsic abnormality of thelymphatic system. It may becaused by insufficient numbersof lymphatic collectors (resultingin aplasia or hypoplasia). Itmay result from an abnormalityof the lymphatic vessels suchas hyperplasia or valvularincompetence (Mortimer, 1998).It may be congenital (present atbirth but not hereditary), or candevelop at puberty or any agethereafter.Secondary lymphoedema isdue to damage or long-termoverload of the lymphaticsystem by extrinsic factorsincluding:8Cancer treatment, e.g.surgery and/or radiotherapy8Recurrent infection8Trauma8Parasitic infection8Obstruction by tumour8Immobility8Venous disease, which will bedescribed now in more detail.Lymphovenous oedemaLymphovenous oedemaoccurs when chronic venousdisease associated with deepvein thrombosis, venoushypertension and chronic legulceration influences capillarypermeability and increasescapillary filtration rates.Venous hypertension is causedby failure of the calf musclepump to return blood back upthe leg. Incompetent valvesin the deep, perforating orsuperficial veins lead to thebackflow of blood and theveins elongate and becometortuous. The resulting increasein pressure leads to leakageof blood particles and fluidinto the tissues. This is usuallycompensated for by a healthylymphatic system.However, a sustained increasein capillary filtration leads toan overload of the lymphaticsystem, which will ultimatelyresult in oedema. Thus, acombined lymphatic andvenous oedema results;lymphovenous oedema. Aslymphatic drainage becomesfurther compromised,lymphostatic fibrosis begins toWound Essentials • Volume 2 • 2007 47

Reviewa swollen foot or toes, increasedexudate from an ulcer site or apoorly healing wound may besigns that oedema is not beingadequately controlled (Figure 3).Figure 2. Ulceration and maceration of the surrounding skin and oedema around theulcer.Figure 3. Swollen toes (Courtesy of St. Giles Hospice).develop leading to a chronicoedema (Green and Mason,2006).Table 1Visible signs of long-term oedema in the lower limb8Positive Stemmer’s sign (Figure 6)8Dry, flaky skin8Skin creases around the ankles and toes (Figure 7)8Hyperkeratosis (Figure 7)8Lymphangioma8Papillomatosis8Increased subcutaneous fat.Chronic oedema ischaracterised as a longstandingoedema that hasbeen present for at least threemonths and does not reduceon elevation of the affectedpart of the body (Green andMason, 2006). With continuedfluid accumulation, skin andtissue changes occur (Table1). Chronic oedema has beenshown to affect a significantnumber of patients with legulceration (Moffatt et al, 2004).In such patients, impairedlymphatic drainage may beidentified around the ulcer siteby the presence of oedema andlocalised swelling at the ulceredge (Figure 2). The presence ofRecognising chronic oedemaA thorough assessment of thepatient will help to identify riskfactors for the development ofchronic oedema and aid in itsdiagnosis. A careful history andexamination should be carriedout to include:8General medical history,including identification ofconditions that may affectthe outcome of treatmentsuch as a history of venousinsufficiency, deep veinthrombosis and cardiachistory8Limb volume measurement toassess the degree of swelling8Assessment of the skin andtissues to identify changesassociated with chronicoedema, noting factors thatmight affect the outcome oftreatment, such as repeatedepisodes of cellulitis, fungalinfections, papillomatosis,and skin allergies, such asdermatitis8Psychosocial assessment todetermine the impact of theswelling on the patient8Circulatory assessment— ankle brachial pressureindex (ABPI) or toe brachialpressure index (TBPI). AnABPI must be calculated toexclude significant arterialdisease. An ABPI must begreater than 0.8 before highcompression can be applied.If below 0.8 refer for furthervascular investigations(Stevens, 2004) beforeundergoing compressiontherapy.48 Wound Essentials • Volume 2 • 2007

ReviewManagement ofchronic odemaLymphoedema managementcomprises four componentsused in combination to providethe most effective reductionand maintenance of swelling.The British Lymphology Society(BLS) recommends a minimumstandard of care for patientswith lymphoedema (Figure 4).Patients who require anintensive (decongestive) oedematreatment, i.e. those patientswith large, swollen, distortedlimbs with skin problems, wouldusually be treated with a courseof multilayer lymphoedemabandaging (MLLB) and possiblymanual lymphatic drainage (MLD),along with skin care, an exerciseprogramme, psychosocialsupport and education. Thisintensive therapy programmeis used to ‘decongest’ the limband/or trunkal region by removingfl uid from the congested tissues,encouraging the movementof fl uid through the lymphaticpathways and reshaping theoedematous limb.MLLB comprises of toebandaging (Figure 5), tubularstockinette, padding (usingeither soft bandage padding orpadding with foam) and layersof short-stretch bandages. Thebandages are usually appliedto the whole leg (toe to thigh)to prevent displacement ofoedema into these areas.This system provides a rigid‘structure’ around the limb andprovides low resting pressuresand high working pressures.Low resting pressure meansthat the bandage appliesconstant low pressure to theskin when the limb is at rest.Skin careMoisturisation/hydration ofthe skinMaintain skin integrityPrevent infectionCompression therapyMultilayer lymphoedemabandaging (MLLB)Compression hosieryLymphoedemaAssessmentSupportMonitoringFigure 4. Four components of lymphoedema management(Adapted from BLS, 2002).Figure 5. Toe bandaging.ExerciseMaintain joint mobilityEnhance lymphatic andvenous fl owLymphatic drainageManual lymphatic drainageSimple lymphatic drainage50 Wound Essentials • Volume 2 • 2007

ReviewFigure 6. Positive Stemmer’s sign.When the muscles contract andexpand (e.g. during exercise)they press against the bandageand the pressure in the limbtemporarily increases. Thisincreased ‘working’ pressurestimulates lymphatic pumpingand reabsorption of lymph(Moffatt, 2000).Management of leg ulcersA graduated, sustainedcompression therapy istraditionally used in themanagement of leg ulcers, witha wound dressing selected asappropriate for the specificwound. A layered bandagingsystem is used and is said tobe more effective than singlelayer systems (Fletcher et al,1997). These systems are onlyapplied below the knee anddo not include the toes. Thebandages are left in situ forup to one week. The choiceof dressing and bandagingsystem will depend upon thepatient’s condition, assessmentand patient choice (Dowsett,2005).Management of leg ulcersand chronic oedema: whichbandaging system?Patients with chronic oedemaand ulceration require a differentapproach to treatment thanthose with venous ulcerationalone. The specific issuesassociated with managing thepatient with lymphoedematousulceration include:8Limb shape distortion8Care of skin creases and folds8Swelling of the toesand forefoot.These issues require a modifiedapproach to the usual venousleg ulcer bandaging regimens(Moffatt et al, 2005).Patients with limb distortionand skin folds or creases willrequire a more specialisedapproach to their careand, if available, workingin conjunction with alymphoedema specialist serviceis useful. The use of paddingor foams is needed to correctthe limb shape, pad out theskin creases and even out thebandage shape to ensure thelimb retains a cylindrical shapein order to maintain the correctcompression gradient(Todd, 2000).In many cases where traditionalvenous leg ulcer bandaging isused for patients with chronicoedema, oedema of the toesand forefoot develops. Oedemaof the toes occurs when thebandages cause pressure onthe dorsum of the foot, pushingfluid down into the toes. Wherevenous leg ulcer bandages havenot been applied far enoughdown the foot, dorsal swellingmay occur. If the lymphaticsin this area become stagnant,secondary skin changes maytake place (Tiwari, 2003), suchas a positive Stemmer’s sign(Figure 6), thickened skin, orpapillomatosis.It has been suggested thattraditional venous ulcerbandaging systems used forpatients with chronic oedemamay result in persistent oedemaof the toes, knees and thighs,exacerbating ulceration andpreventing healing (Williams,2003). ‘Slippage’ of thebandage due to a reduction inswelling, particularly in the earlydays of treatment can lead to atourniquet effect and can causefurther distortion in the shapeof the limb. Hence, MLLB maybe more appropriate for thispatient group.Components of skin careSkin careCare of the skin is a majorconcern when managingpatients with ulceration52 Wound Essentials • Volume 2 • 2007

ReviewFigure 8. Lymphorrhoea. (Courtesy of St.Giles Hospice).Figure 7. Hyperkeratosis and skin creases (courtesy of St Giles Hospice).and oedema. Patients withchronic oedema are at anincreased risk of infection ifthe skin is dry and cracked.This can lead to cellulitis andfurther deterioration in theiroedema. The skin integrity ofthe unaffected skin must bemaintained. Moisturisation ofthe skin is essential to maintainits hydration. An appropriatedressing should be used toprotect the skin around thewound (peri-wound) frommaceration (breakdown causedby moisture), which can occurif excess fluid (exudate) fromthe wound is left in contactwith the skin. Consultationwith tissue viability specialistwill be of benefit in patientswith complicated ulcers.Referral should be made ifthere is any doubt concerningmanagement.Compression and supportCompression and supportare the foundations of goodoedema management and canbe used to reduce swellingand maintain the reduction(BLS, 2002). Often describedas containment (Todd,2000), external support incombination with muscularactivity stimulates both venousand lymphatic drainage. MLLBis recognised as an essentialcomponent of the intensivephase of lymphoedemamanagement (Casley-Smithand Casley-Smith, 1997).In addition to the reductionof oedema, MLLB restoreslimb shape, reduces the riskof skin changes and canhelp to soften subcutaneoustissues and support stretchedskin (Williams, 2003). MLLBenhances lymph formationby increasing movement ofinterstitial fluid into the initiallymphatics by increasing tissuepressure when the patientmoves (Leduc et al, 1990;Thomas, 1996; Casley-Smithand Casley-Smith 1997).MLLB is indicated for patientswith:8Fragile/damaged or ulceratedskin8Fibrotic skin changes, e.g.hyperkeratosis, papillomatosis8Lymphangioma8Lymphorrhoea (Figure 8)8Solid, non-pitting, fibroticsubcutaneous tissues8Skin folds/creases.MLLB is contraindicated forpatients with:8Acute infection, e.g. cellulitis8Arterial insufficiency8Deep vein thrombosis (DVT)8Severe cardiac failure.Components of the MLLBsystem such as padding,toe bandaging and full legbandaging may be incorporatedinto venous bandaging systems,as they may help to reduce theoedema thereby enhancinghealing by improving deliveryof nutrients to the cells andspeeding up the removal ofwaste products (Williamsand Keller, 2005). However,bandaging the full leg doesrequire some skill and the fourlayersystem may not lend itselfreadily to this technique dueto the high resting pressuresexerted by the bandages at theknee joints and thigh.Ideally, MLLB should bereapplied daily especially inthe early stages of treatmentas the bandages may becomeloose or slip due to reductionin limb volume. However, asthe treatment continues theuse of cohesive short-stretchbandages within the MLLBsystem can reduce slippage54 Wound Essentials • Volume 2 • 2007

Reviewand allow bandages to stayin place for longer (Williams,2006), thereby reducing nursingtime and frequency of dressingchange.The choice of ulcer dressingshould also be consideredto prevent skin irritation andreaction. Using a tubularbandage over the dressingand under the padding shouldhelp to reduce skin reactionsand provide protection tothe tissues. Toe bandagingin conjunction with venousbandaging systems can help toreduce toe swelling. However, itis also important that bandagesare applied from toe to kneewith the correct technique toavoid forefoot swelling.For immobile patients, acombination of venousbandaging that produces ahigher resting pressure may bemore useful than MLLB dueto the reduced muscle activity(Moffatt et al, 2005).For every patient, the clinicianneeds to assess limb shape,tissue condition, and the extentof oedema in order to decidewhich bandage techniqueshould be used. If in doubt,management should bediscussed with a specialist.Exercise and movementMobility and exercise playan important role in themanagement of patients withlymphoedema and ulceration,especially if the patient isundergoing MLLB. Movementcan improve lymph flow byenhancing the muscle pumpaction which has an effect onlymphatic and venous flow,thereby removing fluid from thetissues.Mortimer et al (1990) and Goodyet al (2001) suggest that passivemovement of the foot can causesignificant volume change in thelower limbs (Vaqas and Ryan,2003). Foot and ankle exercisesshould be encouraged topromote calf pump action andthigh and hip exercises can helpwith fluid movement from thethigh.Manual lymphatic drainageIn some cases it may beappropriate to include manuallymphatic drainage (MLD) inthe treatment plan of patientswith ulceration and chronicoedema. Manual lymphaticdrainage is a type of massagewhich is designed to utilisethe skin lymphatic drainageroutes to redirect fluid fromthe oedematous regions toareas with healthy lymphatics.It requires specific gentlemovements on the skin tostimulate lymph flow and openup collateral lymphatic vessels.This may accelerate andstabilise the treatment results(Strossenreuter, 2003). MLDmay also be performed onthe ulcer site. This will requirereferral to a lymphoedemaspecialist practitioner forappropriate treatment.A case study will now bepresented that demonstratesthe effective management ofa patient with lymphovenousoedema and leg ulceration.Case studyPatient X, a 45-year-old malehad significant skin and muscleFigure 9. Ulcer healing after 2 weeks oftreatment.Figure 10. Compression hosiery wasused to maintain limb volume reduction.loss in both thighs following acrush injury. He consequentlydeveloped lymphoedemaof both legs and underwenta course of decongestivelymphatic therapy to reducethe swelling to his right legin 1999. Following the useof compression hosiery onboth limbs, the swellingwas contained. In 2005he developed a deep veinthrombosis (DVT) in his leftthigh and went on to developsymptoms of chronic venousinsufficiency in addition tolymphoedema. He developeda small ulcer to the medialaspect of the ankle abovethe mallelous of his left legthat was treated successfully.56 Wound Essentials • Volume 2 • 2007

ReviewUnfortunately, early in 2006 hedeveloped further ulceration tohis left limb. He was seen bya healthcare professional whoinformed him that he could notreceive compression bandagingbecause he had lymphoedema.At that point a hydrocolloiddressing was applied to theulcer site. Patient X was toldto remove the dressing sevendays later and come back ifhe had further problems. Aftertwo days he was experiencingexcruciating pain at theulcer site and contacted thelymphoedema service. Onassessment he had an ulcer tothe gaiter area of the left leg thatwas odorous and producingexudate. The skin surroundingthe ulcer was macerated andinflamed.Patient X’s leg was oedematouson the foot and from mid-calfto thigh, but the ankle area wasindurated and he had developeda typical ‘inverted champagnebottle’ appearance. This was aproblem because when normalvenous leg ulcer bandagingwas applied, the shape of hisleg caused the bandages to slipand further distort the shape ofhis lower leg.ABPI was normal and therewere no signs of arterialinsufficiency. A swab was takenfor micro-culture and sensitivity.A non-adhesive dressing wasapplied to the ulcer. The limbwas bandaged using a modifiedmultilayer system comprisingtoe bandages, tubifast, softwool padding and cohesiveshort-stretch bandages. A fullleg bandage was not appliedas Patient X had restrictedmovement in his right legdue to the rigidity of his kneefollowing the accident. It wasimportant not to impede hismobility further by restrictingthe movement in his left kneethrough bandage application. Itwas also necessary to pad outthe distorted shape at the ankleto avoid excessive pressure.The wound swab came backpositive for Staphylococcusaureus and Patient X wasprescribed flucloxacillin. Thedistrict nurses replaced hisbandages a few days later andhe returned to the clinic a weekafter his first appointment.There were already signs thatthe ulcer was healing and hehad not experienced any painsince having the bandagesapplied. This treatment planwas continued for a furthertwo weeks with the ulcerbeginning to heal very quickly(Figure 9). He was monitoredfor signs of swelling to theknee or thigh and, after threeweeks, was fitted with custommadecompression hosiery tomaintain limb volume reduction(Figure 10).ConclusionRecognition of chronic oedemain patients with ulcerationis essential if treatment isto be managed effectively.A combined approach tomanagement is essentialto facilitate successfuloutcomes for this client group.Assessment and correctdiagnosis is crucial to therecognition of lymphoedema.Referral to the lymphoedemaspecialist and/or tissue viabilityservices will benefit thepatient in the long-term andis an essential component ofmultidisciplinary teamwork.Key Points8 Chronic oedema affects a significantproportion of the population.8 Chronic oedema and ulcerationrequire a modified, succinctapproach to management.8 Thorough assessment of achronically swollen limb is essentialif the appropriate treatment is to becarried out.Simple changes to bandagingtechniques to address thelymphatic component ofswelling can bring about a quickresponse to treatment. Thisnot only improves the patients’quality of life but reduces thecosts of dressings and nursingtime (Stalbow, 2004). Leg ulcerpractioners and lymphoedemaservices should adopt anintegrated approach to meetthe needs of patients withlymphoedema/chronic oedemaand leg ulcers. WEArmer J, Fu MR, WainstockJH, Zagar E, Jacobs LK (2004)Lymphoedema following breastcancer treatment, including sentinellymph node biopsy. Lymphology37: 73–91Badger CM, Peacock JL,Mortimer PS (2000) Arandomised, controlled, parallelgroupclinical trial comparingmultilayer bandaging followedby hosiery versus hosiery alonein the treatment of patients withlymphoedema of the limb. Cancer88(12): 2832–7Board J, Harlow W (2002)Lymphoedema 1: components andfunction of the lymphatic system.Br J Nurs 11(5): 304–9Wound Essentials • Volume 2 • 2007 57

ReviewBoard J, Harlow W (2002)Lymphoedema 2: classification,signs, symptoms and diagnosis. BrJ Nurs 11(6): 389–95Board J, Harlow W (2002)Lymphoedema 3: the availabletreatments for lymphoedema. Br JNurs 11(7): 438–50British Lymphology Society (2002)Strategy for LymphoedemaManagement. BLS, Sevenoaks, KentCallum M (1992) Prevalence ofchronic leg ulceration and severechronic venous disease in westerncountries. Phlebology 1 (suppl): 6–12Casley-Smith J, Casley-SmithJR (1997) Modern Treatment forLymphoedema. 5th edn. TerracePrinting, Adelaide, AustraliaDowsett C (2005) Assessment andmanagement of patients with legulcers. Nurs Stand 19(32): 65–72Fletcher A, Cullum N, SheldonTA (1997) A systematic review ofcompression treatment for venousleg ulcers. Br Med J 315(7108):576–80Godoy JMP, Godoy MFG (2001)Development and evaluation of anapparatus for lymph drainage. Eur JLymphology 9: 121Green T, Mason W (2006) Chronicoedemas: identification and referralpathways. Br J Comm Nurs 11(4):S8–S16Leduc A et al (1990) Le traitementPhysique de l’oedeme du bras.Monographies de Bois-larris, 2ndedn. Masson, ParisLevick JR, McHale N (2003) Thephysiology of lymph production andpropulsion In: Browse N, BurnandKG, Mortimer PS, eds. Diseases ofthe Lymphatics. Arnold, London:44–64Moffatt CJ (2000) CompressionTherapy. J Community Nurs 14:26–36Moffatt CJ, Franks PJ, DohertyDC et al (2003) Lymphoedema: anunderestimated health problem.QJM 96(10): 731–8Moffatt CJ, Franks PJ, Doherty DC,Martin R, Blewett R, Ross F (2004)Prevalence of leg ulceration in aLondon population. QJM 97(7):431–7Moffatt CJ, Morgan P, DohertyD (2005) The LymphoedemaFramework: a consensus onlymphoedema bandaging. In:European Wound ManagementAssociation (EWMA) FocusDocument: LymphoedemaBandaging in Practice. MEP Ltd,LondonMoffatt CJ, Franks PJ, Doherty DC,Martin R (2004) Prevalence of legulceration in a London population.QJM 97: 431–7Morgan PA, Moody M, Franks PJ,Moffatt CJ, Doherty DC (2005)Assessing community nurses’ levelof knowledge of lymphoedema. BrJ Nurs 14(1): 8–13Mortimer PS (1998) Thepathophysiology of lymphoedema.Cancer (suppl) 83(12): 2798–802Mortimer P (2000) AcuteInflammatory Episodes In: TywcrossR, Jenns K, Todd J, eds (2000)Lymphoedema. Radcliffe MedicalPress. Oxon: 130–9Mortimer P, Browse N (2003)The relationship between thelymphatics and chronic venousdisease. In: Browse N, BurnandKG, Mortimer PS (2003) Diseasesof the Lymphatics. Arnold, London:293–6Mortimer PS, Levick JR (2004)Chronic peripheral oedema: thecritical role of the lymphatic system.Clin Med 4(5): 448–53Mortimer PS, Simmonds R, RezvaniM, Robbins M, Hopewell JW,Ryan T (1990) The measurementof sklin lymph flow by isotopeclearance-reliability, reproducibility,injection dynamics and the effectof massage. J Invest Dermatol 95:677–82Stalbow J (2004) Preventingcellulitis in older people withpersistent lower limb oedema. Br JNurs 13(12): 725–32Stanton A, Modi S, Mellor S,Levick R, Mortimer P (2006)Diagnosing breast cancer-relatedlymphoedema in the arm. JLymphoedema 1(1): 12–15Stevens J (2004) Diagnosis,assessment and managementof mixed aetiology ulcers usingreduced compression. J WoundCare 13(8): 339–43Strossenreuter RHK (2003)Practical instructions fortherapists-general requirements forcompression bandages. In: FoldiM, Foldi E, Kubik S (eds) Textbookof Lymphology for Physicians andLymphoedema Therapists. Urbanand Fischer, San Francisco: 564–7Thomas S (1996) High compressionbandages. J Wound Care 5: 40–3Tiwari A, Cheng, KS, Button Met al (2003) Differential diagnosis,investigation and current treatmentof lower limb lymphoedema. ArchSurg 138(2): 152–61Todd J (2000) Containment in themanagement of lymphoedema. In:Tywcross R, Jenns J, Todd J, eds.Lymphoedema. Radcliffe MedicalPress, OxfordVaqas B, Ryan TJ (2003)Lymphoedema: Pathophysiologyand management in resource-poorsettings — relevance for lymphaticfilariasis control programmes. FilariaJ 2(1): 4Williams AF (2003) Themanagement of lymphoedemaof the lower limbs. J Comm Nurs17(8): 34–44Williams AF, Keller M (2005)Practical guidance onlymphoedema bandaging ofthe upper and lower limbs. In:European Wound ManagementAssociation (EWMA). FocusDocument: LymphoedemaBandaging in Practice. MEP Ltd,LondonWilliams A (2006) A clinical auditof Actico cohesive short stretchbandages in lymphoedema. JComm Nurs 20(2): 4–858 Wound Essentials • Volume 2 • 2007