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

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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
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