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

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

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