Using compression therapy in complex situations

Document Sample
Using compression therapy in complex situations Powered By Docstoc

Using compression therapy
in complex situations
Patients presenting with ulceration will often have other chronic illnesses such as diabetes
mellitus and osteoarthritis. Compression therapy remains the mainstay of treatment for the
majority of these patients, although in some it will be contraindicated. This article stresses
the importance of assessment of ulcer aetiology and will discuss the treatment of patients with
ulceration who have complex health needs, including those with diabetes, rheumatoid arthritis,
haematological problems such as sickle cell anaemia, cardiac problems, and wounds caused by trauma.

                                                                  Christine Moffatt

   KEY WORDS                                             Patients with diabetes
                                                         Many textbooks state that                Table 1
   Compression therapy                                   compression therapy should not be        Factors affecting wound healing
   Ulceration                                            used in patients with diabetes. This
   Diabetes                                              is because of the risk of concurrent
                                                         peripheral arterial occlusive disease    8 Peripheral arterial occlusive disease that leads
   Rheumatoid arthritis
                                                         and the concern that sensory               to reduced perfusion and low oxygen levels
   Sickle cell anaemia                                                                              that result in tissue breakdown and gangrene
                                                         neuropathy will prevent a patient from
   Pre-tibial crest injuries                             detecting whether the compression is       (Kite and Powell, 2007)
                                                         causing trauma. However, patients with   8 Smoking is a major risk factor for peripheral
                                                         diabetes are just as likely to suffer      vascular disease (PVD) (Burns et al, 2003). In

        here is increasing evidence that                 from a venous ulcer as those without.      addition to its role in accelerating arterial
        the proportion of patients with                                                             disease, it is also a potent vasoconstrictor,
        complex ulceration is increasing                     Such patients with venous              further reducing local tissue oxygen perfusion
(Moffatt et al, 2004). There may                         ulceration require compression           8 Poor immune function, placing the patient
be many reasons for this, the most                       therapy and, providing their condition     at risk of overwhelming infection (Kite and
important factor being the increase in                   is stable, they may heal uneventfully.     Powell, 2007).
peripheral arterial occlusive disease in                 Others may take longer to heal,          8 Reduced neutrophil activity increases the
the very elderly (Morison et al, 2007).                  although the exact reason for              risk of opportunistic bacteria causing severe
As age increases, so does the chance                     the delay may not be obvious               infection (Edmonds, 2007).
of having other chronic illnesses such                   (Marston, 2007).                         8 Increased risk of infection with a blood
as diabetes mellitus and osteoarthritis.                                                            glucose of > 7 mmol/l (International Working
Identification of the ulcer aetiology                        There are a number of factors          Group on the Diabetic Foot, 2003).
remains a key priority of assessment.                    thought to affect wound healing in the   8 Patients with two or more factors
The true role that other health                          patient with diabetes (Table 1), who       complicating the ulcer aetiology
issues play in ulcer healing is often                    frequently present with other medical      (International Working Group on the
difficult to determine. Nevertheless,                    conditions or complications                Diabetic Foot, 2003)
compression therapy remains the                          of diabetes.                             8 Reduced serum albumin levels of < 30 gm/dl
mainstay of treatment for the majority                                                              due to infection, starvation, renal failure or
of these patients despite their complex                  Assessment issues                          acute stress (International Working Group on
healthcare needs and healing can be                      To use compression safely and              the Diabetic Foot, 2003)
achieved, although more slowly, in                       effectively, a number of issues          8 Other diabetic complications, such as
many cases.                                              must be addressed within a                 retinopathy and nephropathy, are important
                                                         comprehensive, structured assessment.      indicators that delayed wound healing may
                                                         If there is any doubt, the patient         occur (International Working Group on the
Christine Moffatt is Honorary Professor in Nursing and
                                                         should be referred for a specialist        Diabetic Foot, 1999).
Health Care, Glasgow University and Co-Director of the
Centre for Research and Implementation of Clinical       opinion before treatment with
Practice (CRICP), London                                 compression commences.

  84      Wounds       UK,   2008, Vol 4, No 4
                                                                                             Clinical PRACTICE DEVELOPMENT

                                                                                           vessels rarely occurs, therefore, it
                                                                                           gives a more accurate assessment
                                                                                           of the arterial status
                                                                                         8 If the arterial status of the patient
                                                                                           cannot be determined, specialist
                                                                                           referral for further vascular
                                                                                           assessment should be made.

                                                                                         Assessment of peripheral neuropathy
                                                                                         Neuropathy occurs in the majority of
                                                                                         patients with diabetes (Edmonds, 2007).
                                                                                         This places the patient at risk of callus
Figure 1. The at-risk diabetic foot, with hallux                                         formation and foot ulceration due to
valgus, crowded toes and callus formation over                                           the changed biomechanics of the foot
the metatarsal heads.                                                                    that cause areas of high pressure and
                                                                                         friction (Figure 1). Regular assessment of
                                                                                         neuropathy using a 10 g monofilament
                                                                                         should be undertaken in all patients
                                                                                         with diabetes. In addition, it is important
                                                                                         to pay particular attention to:
                                                                                         8 Areas at risk of pressure damage
                                                                                              from compression
                                                                                         8 Areas of callus formation or
                                                                                              previous foot ulceration
                                                                                         8 Foot deformities, eg. hammer toes,
                                                     Figure 3. Deep pressure necrosis.        hallux valgus, Charcot deformity,
                                                                                              prominent metatarsal heads,
                                                                                              dropped arch
                                                                                         8 Toes, interdigital infection, emboli
                                                                                              (Figure 2)
                                                                                         8 Joint function
                                                                                         8 Quality of the skin and signs of
                                                                                         8 Nails, nail deformities
                                                                                              and infection
                                                                                         8 Footwear.

Figure 2. Arterial emboli.                                                               Removal of callus
                                                     Figure 4. Heel pressure ulcer.      Callus formation can be rapid,
    The following key priorities relate                                                  particularly in patients suffering from
to the safe use of compression in                                                        hyperglycaemia. Common areas of
patients with diabetes.                                                                  callus formation are over the plantar
                                                                                         surface of the foot, particularly where
Exclusion of peripheral arterial occlusive disease                                       there are exposed metatarsal heads.
A patient’s arterial status should be                                                    Compression bandaging traditionally
assessed using a clinical history and                                                    extends to the base of the toes.
Doppler ultrasound. Recording a                                                          This will mean that the compression
resting pressure index in a patient with                                                 is applied over this area acting as a
diabetes can be difficult, due to:                                                       secondary source of pressure and
8 Calcification of the arteries which                                                    friction. The callus area may need to
     prevents the artery from being                                                      remain exposed to avoid this risk and
     occluded. As a result, a false,                                                     to allow for the regular removal of
     very high systolic pressure is                                                      callus by the diabetic podiatrist.
     recorded which does not give an
     accurate picture of the patient’s                                                   Identification of sub-keratotic haematoma
     arterial status                                                                     If the patient has neuropathic foot
8 Toe pressure may be useful in this                                                     ulceration or evidence of haemorrhage
     group as calcification of the toe               Figure 5. Crowding of toes.         below the callus, compression should

                                                                                             Wounds   UK,   2008, Vol 4, No 4   85

not be applied without specialist
advice. These patients require an
urgent specialist referral to the
diabetic team and debridement by
the diabetic podiatrist

Foot deformities and pressure damage
Foot deformities, such as claw toes,
hammer toes, prominent hallux valgus
(bunions) and bunionettes are all
areas at risk of compression damage.
Other neuropathic changes include
loss of the small intrinsic muscles and
subcutaneous tissue in the forefoot
area. High compression can result          Figure 6. Charcot foot deformity.
in deep pressure necrosis over the
dorsum of the foot (Figure 3). The         Footwear
extensor tendon may be prominent,          It is vital to assess the patient’s
requiring extra protection.                footwear. Patients with neuropathy are
                                           frequently found to be wearing shoes
    The area of the heel is rarely         that are too tight and the feet should
described as an area that is associated    be checked for signs of pressure
with compression damage. However,          damage (Edmonds, 2007). When
compression may exacerbate the risk        compression is being considered, it
of heel pressure ulceration in immobile    is important to assess how this will
patients who keep their limb in the        influence their regular footwear.
same position for long periods of
time (Figure 4). The loss of sensation     Previous history of foot ulceration
prevents these patients from being         Specialist advice should be sought
alerted to the need to change position.    before applying compression to
                                           patients with a previous history of
    While compression bandaging            foot ulceration or those wearing
should not extend over the toes,           custom-made shoes. It is vital that
care must be taken to ensure that          the compression does not become
compression will not exacerbate toe        wrinkled when the foot is placed
deformities or cause tissue damage.        in the shoe, as the patient with
Crowding and overlapping of toes           neuropathy will be unable to tell if        Figure 7. Vasculitic ulceration associated with
are common problems leading to             damage is occurring.                        rheumatoid arthritis.
interdigital pressure ulceration with
increased risk of infection (Figure 5).    Contraindications to compression therapy    Patients with a reduced ankle to brachial pressure
                                           There are a number of clinical              index (ABPI)
Reduced mobility                           situations when compression should          Although reduced compression is
Many factors influence the mobility        not be used in a patient with diabetes      recommended for patients without
of these patients. Reduced ankle           except under specialist supervision.        diabetes with a reduced ABPI of 0.6–
movement is a common problem.                                                          0.8, compression should be avoided
There are a number of reasons why          Concurrent neuropathic foot ulceration      in patients with diabetes with an ABPI
this may occur. Long-term venous           Venous ulceration may occur in a            below 0.8 until specialist opinion has
ulceration is associated with a            patient with concurrent neuropathic         been sought. Marshall (2004) outlines
progressive loss of ankle function,        foot ulceration. In addition to the risks   a recommended protocol to assist
particularly when compression is being     associated with reduced sensation,          practitioners when undertaking
used. Patients who have a completely       compression should not be applied           an ABPI.
fixed ankle joint are at particular risk   over the ulcerated area, as this may
of delayed healing due to poor venous      act as an additional pressure source        How to choose the correct compression
return. Patients with diabetes also        and can prevent regular inspection of       Elastic or inelastic, multi-layer high
develop reduced ankle function due to      the foot. In a similar manner, a Charcot    compression bandaging is the
the glycosylation in the subcutaneous      deformity with ulceration should not        treatment of choice. In young patients
tissues causing stiffness and reduced      be treated with compression therapy         who wish to self-care, compression
function (Edmonds, 2007).                  (Figure 6).                                 hosiery may be a useful option.

 86    Wounds   UK,   2008, Vol 4, No 4

 Table 2
 Different compression regimes for patients with diabetes

 Self-care regimens, using bandages and compression garments, to be considered for patients:
 8 With good eyesight who are able to undertake dressings and observe their wound for signs of
   progress or deterioration
 8 Wishing to self-manage
 8 With an adequate hyperglycaemic control
 8 With a clear understanding of their condition and its treatment
 8 With no neuropathy
 8 With no history of neuropathic foot ulceration
 8 With the ability to concord with professionally prescribed treatment.

 Elastic multi-layer high compression bandaging (higher resting pressure), suitable for patients who:
 8 Are young and fit
 8 Have a normal ankle to brachial pressure index with triphasic waveforms
 8 Have no history of cardiovascular disease                                                              Figure 8. Patient with rheumatoid arthritis and
 8 Have no previous treatment for peripheral arterial occlusive disease                                   ulceration from compression damage.
 8 Have minimal or no peripheral neuropathy
 8 Have varying levels of mobility, including poor mobility and those who are chairbound
 8 Have control of oedema, particularly in the immobile patient.

 Inelastic multi-layer high compression bandaging (lower resting pressure), suitable for patients with:
 8 Ankle to brachial pressure index > 0.8 with biphasic or triphasic waveforms
 8 Good mobility (to assist the action of the bandage during walking)
 8 Concerns over distal perfusion at night when wearing bandaging with the foot elevated
 8 Severe pain which prevents the use of high pressure elastic bandaging.

                                                                                                          Figure 9. Ulceration due to sickle cell disease.

    When choosing a regimen for a                            enough to safely accommodate                 arthritis are substantially more at
patient with diabetes, the factors in                        compression                                  risk of developing leg ulceration, and
Table 2 may help decision-making.                          8 If patient is wearing or requires            an estimated 5–10% will experience
                                                             custom-made shoes because                    ulceration at some point in their lives
Application issues                                           of foot ulceration or previous               (Cawley, 1987; Pun et al, 1990). About
It is important to consider the                              ulceration, a specialist referral            18% of these ulcers are vasculitic
principles of safe application of                            should be made                               (Pun et al, 1990) (Figure 7). Poor ankle
compression and reduction of pressure                      8 In rare cases, compression can               mobility causing loss of calf muscle
damage. In addition, the following                           be applied from ankle to knee in             pump and ‘pseudo-venous disease’ is
points should be considered:                                 patients who wear custom-made                another major factor (Cawley 1987;
8 The use of foam dressings or                               shoes due to foot deformities. This          Moffatt et al, 2004). The general health
     podiatric felt to redistribute                          type of footwear prevents oedema             status of many of these patients is
     pressure away from vulnerable                           formation in the foot. This type of          poor. Poor nutrition due to loss of
     areas                                                   problem should only be managed               appetite, functional difficulties, fatigue,
8 Applying small, soft foam shapes                           under specialist supervision.                stress and anxiety are common
     between the toes to prevent                                                                          (Ryan, 1995).
     interdigital ulceration                               Patients with rheumatoid arthritis
8 Reshaping the limb to protect                            Rheumatoid arthritis is a chronic,             Recognising rheumatoid ulceration
     prominent extensor tendons                            progressive inflammatory tissue                These ulcers are often associated
8 Changing to a bandage or bandage                         disorder of unknown origin causing             with high levels of rheumatoid factor
     system with a lower sub-bandage                       joint stiffness, ankylosis (fixation of a      and severe arthritis. However, they
     resting pressure                                      joint), and associated joint deformity. In     may also be seen in those with stable
8 Reducing pressure over vulnerable                        addition, the auto-immune component            rheumatoid arthritis. The ulcers tend
     areas by changing the technique of                    of the disease can affect other systems        to have a scalloped, undulating border.
     bandage application                                   including the skin (Oliver and Mooney,         It is not uncommon for rheumatoid
8 Ensuring that the shoes are large                        2002). People with rheumatoid                  ulcers to have a component of

 88      Wounds      UK,   2008, Vol 4, No 4

ischaemic or venous insufficiency,               poor healing, even if it is not the          Management requires a co-
which often makes the condition                  primary cause of the ulcer               ordinated approach with the
more difficult to diagnose. Rheumatoid       8   If there is poor ankle mobility,         haematology team playing
ulcers are generally considered to be            venous hypertension is likely to         an impor tant advisory role
multifactorial in aetiology.                     be impeding healing. Leg elevation       (Olujohungbe and Anionwu, 2007).
                                                 and ankle exercises will need to         Blood transfusions (simple ‘top up’
Medical management                               be taught and encouraged, as             or exchange) have been successfully
It is important to recognise that this           tolerated                                used in an uncontrolled manner to
is a type of leg ulcer caused by a           8   If vasculitis is suspected, refer for    treat sickle cell leg ulcers. The healing
systemic disease process. The initial            an urgent specialist opinion before      effect may be directly due to relief
priority in these circumstances is to            starting compression                     of tissue anoxia of the corrected
ensure that the appropriate systemic         8   Liaising with the patient’s              haemoglobin but also by limiting
therapy is used, in addition to local            rheumatologist ensures a                 ischaemia arising from repeated
treatment of the wound and the                   coordinated approach to care             vaso-occlusion (Chernoff et al, 1954;
use of appropriate levels of                 8   Monitoring and controlling wound         Serjeant, 2001).
compression. Medical treatment of                infection. The drugs used for
this condition is difficult. Many patients       rheumatoid arthritis may also                Pain may be severe, excruciating
are already receiving high doses of              reduce immunity so that fungal           and neuropathic in origin. Simple
corticosteroid therapy and other                 infections such as tinea pedis           analgesia is inadequate and opioid
immunosuppressive drugs. Delayed                 and ringworm may develop and             analgesia and neuroleptic drugs
wound healing and susceptibility to              place the patient at risk of severe      may be required. Referral to a pain
infection are common problems.                   bacterial infection. Osteomyelitis       specialist is frequently necessary.
                                                 is a common complication and is          Additional management issues
Using compression therapy                        particularly found in the toes.          include:
Compression therapy may be of                                                             8 Wound debridement — adequate
some value with rheumatoid arthritis         Haematological problems, such as sickle          pain relief during and after the
because of the associated venous             cell ulceration                                  procedure is essential
insufficiency. However, it may cause         Up to 70% of people with sickle cell         8 Compression therapy
excruciating pain in a small percentage      anaemia are likely to develop a leg          8 Overnight high leg elevation
of patients and in these cases should        ulcer (Serjeant, 2001). Ulceration               — this may drastically improve
not be used until the condition has          often begins in the mid- to late-                the chances of healing
stabilised and the pain reduced. It          teens and is most frequent in males          8 Preventing wound infections
is often difficult to predict which          of Caribbean origin. The exact               8 Systemic antibiotics — these
patients will experience pain and it is      mechanisms are not fully understood,             should be reserved for acute
essential to ensure that vasculitis has      but it is thought to involve a                   infection with cellulitis. Treatment
been excluded, as compression will           combination of chronic anaemia,                  may need to continue for a
not only cause excruciating pain but         venous hyper tension, trauma and                 number of weeks due to poor
may cause rapid tissue necrosis due to       localised microcirculatory damage,               tissue perfusion. Consultation
the already damaged microcirculation         due to the affected cells clumping in            with a microbiologist is helpful if
(Figure 8).                                  the small vessels. Factors to consider           recurrent infections occur
                                             when managing these patients                 8 Skin grafts — these may be
    Compression should always be             include:                                         very effective at reducing
introduced slowly (a low pressure of         8 Sickle cell ulcers tend to be slow             pain, although the recurrence
less than 25 mmHg) and tailored to               to heal and recurrence is common             rate is high. Following grafting,
the patient’s tolerance and pain level.      8 Ulceration occurs most frequently              compression therapy must be
The level of pressure can be increased           in those with sickle cell disease, but       used as soon as the patient is
if well tolerated. The risk of tissue            can also occur in those with sickle          mobile to prevent graft rejection
trauma from poor bandaging is high               cell trait                               8 Avoidance of standing for
and limb deformities require additional      8 Ulceration is rare in those with               prolonged periods of time
padding for protection.                          Beta thalassaemia                        8 Psychological suppor t — this
                                             8 Ulcers have a similar appearance               is essential as many of these
   Great care should be taken to                 to atrophe blanche                           patients are young and are
ensure correct application of the            8 They occur around the malleoli                 struggling with careers and the
bandage. A number of other factors               and tend to be painful and sloughy           financial implications of this
should be considered when managing               and are frequently misdiagnosed as           disabling condition.
these patients, namely:                          a venous ulcer (Figure 9).               Many patients with sickle cell
8 The presence of rheumatoid                 There is as yet no evidence-based            ulceration tolerate multi-layer
    arthritis will be contributing to        treatment for sickle cell ulceration.        compression regimens.

 90    Wounds    UK,   2008, Vol 4, No 4

Patients with cardiac failure                 8 Large blisters may develop that          and Margolis, 2007). A number
There is considerable debate                    may eventually lead to ulceration        of wounds that are initially considered
concerning the use of compression             8 Oedema may extend to the thighs          traumatic may ulcerate, one of
therapy in patients with heart failure.         and eventually to the genitalia and      the most frequent being the
This is because compression reduces             sacral area                              pre-tibial laceration.
the local blood volume of the legs            8 Increased shortness of breath on
by redistributing blood towards                 exertion, during exercise or when        Pre-tibial crest injuries
the central parts of the circulation            lying down                               Pre-tibial crest injuries are common in
(Mostbeck et al, 1977). This can              8 The jugular vein may be distended        the elderly due to falls and knocks to
seriously affect cardiac function by          8 Patients may feel generally unwell       the leg. They are frequently treated in
increasing the preload to the heart           8 Generalised tiredness                    accident and emergency units where
and influencing cardiac output by 5%.         8 Other cardiac symptoms may               the flap of tissue is either glued or
This can precipitate cardiac failure in         include atrial fibrillation              secured back in position using 3M™
those at risk and worsen the situation        8 Previous associated cardiovascular       Steri-Strip™ Skin Closures. If the skin
in those with established heart                 disease such as myocardial               is damaged, the flap may be removed
failure. Although rare, death has been          infarction.                              and a dressing applied.
reported from the introduction of
compression therapy in patients with          Using compression therapy                      In patients who are fit and young
decompensated heart failure.                  When the cardiac failure has been          with no factors influencing healing, the
                                              assessed and treated it is possible        wound can heal uneventfully. However,
Recognising oedema due to heart failure and   to slowly introduce compression            in the elderly, the wound often fails to
combination oedemas                           therapy. The following issues should be    heal and a haematoma may develop
It is important to differentiate oedema       considered:                                beneath the flap. Infection is an
caused by cardiac failure from other          8 Apply reduced compression of less        important complication of haematoma
forms of oedema. If heart failure                  than 25 mmHg initially                due to the breakdown products that
is suspected, a medical assessment            8 In severe cases of heart failure,        accumulate in the wound and the
should be performed and appropriate                begin by applying compression         presence of bacteria. The area may
drug therapy with diuretics                        to one leg                            rapidly deteriorate into an ulcer with
commenced. Compression should not             8 Carefully monitor any increase in        the skin flap sloughing off.
be started until a correct diagnosis is            symptoms such as breathlessness
made. In a proportion of patients the         8 Check that fluid is not                      One of the reasons for poor
leg oedema is due to a combination of              accumulating in the thigh or groins   healing over the tibial crest is the
factors, these may include:                   8 If well-tolerated and the cardiac        relatively poor vascular supply to this
8 Cardiac insufficiency                            symptoms are stable, compression      area. Lack of subcutaneous tissue over
8 Venous disease                                   can be introduced to both limbs       the bony prominence may also delay
8 Lymphoedema                                 8 Levels of high compression may           healing. Inappropriate early treatment
8 Certain drug therapies                           be tolerated in patients with         of the wound may influence the
8 Dependency oedema due to                         controlled heart failure              patient’s progress.
     problems with mobility and               8 If there has been extensive
     breathlessness on lying flat                  erythema and blistering, ensure           Patients attending A&E may be
8 Respiratory disease                              all these areas are covered with a    poorly assessed. Skin flaps that are no
8 Renal disease                                    non-adherent dressing to prevent      longer viable may be replaced rather
8 Liver failure                                    the cotton tubular bandage from       than removed, and risk factors such as
8 Peripheral arterial occlusive                    adhering to the broken skin           the presence of venous disease or mild
     disease.                                 8 If symptoms worsen, stop                 ischaemia that will influence healing,
                                                   compression therapy and refer the     may not be identified.
Features of cardiac oedema include:                patient for a medical assessment.
8 Quick or more insidious                                                                    Oedema frequently occurs
   development of oedema                      Traumatic causes of ulceration             following this injury, further influencing
8 The oedema is predominantly                 Many ulcers begin following a minor        the potential for delayed wound
   soft and pitting, although chronic         trauma and it is the underlying disease    healing. The following aspects should
   heart failure may eventually lead          process that prevents normal wound         be considered when treating these
   to the fibrotic skin changes seen in        healing from occurring. The definition     patients:
   lymphoedema                                of when a wound becomes an ulcer           8 Any loose dead skin should be
8 The sudden increase in oedema               has not been established, although              carefully removed ensuring that
   may cause pronounced erythema              epidemiologists frequently refer to a           there is no further damage
   and leakage of fluid from                  wound that fails to progress over a        8 Any residual haematoma should be
   the tissues                                period of four or six weeks (Kantor             drained (debridement and removal

 92     Wounds   UK,   2008, Vol 4, No 4

      of the haemaotma should only be           legs associated with sickle cell anaemia. J
      carried out by a suitably trained         Am Medical Assoc 155: 1487–91
      specialist nurse)                         Edmonds M (2007) The diabetic foot. In:             Key Points
8     Antibiotics should be prescribed          Morison M, Moffatt CJ, Franks PJ, eds. Leg
      if there are signs of cellulitis (pain,   Ulcers: A problem-based learning approach.
                                                Mosby, Elsevier, Edinburgh                       8 Compression therapy
      erythema, increased exudate and                                                              remains the mainstay of
      oedema)                                   Falanga V (2007) Inflammatory ulcers. In:           treatment for ulceration
8     The wound should be covered               Morison M, Moffatt CJ, Franks PJ, eds. Leg
                                                Ulcers: A problem-based learning approach.
                                                                                                   despite some patients’
      with a totally non-adherent                                                                  complex healthcare needs.
                                                Mosby, Elsevier, Edinburgh
      dressing that allows for exudate
      to wick away from the wound.              International Working Group on the
                                                Diabetic Foot (2003) International               8 Before compression
      Dressings such as Mepitel®
                                                consensus on the diabetic foot. International      therapy can be used for
      (Mölnlycke Healthcare) that               working group on the diabetic foot. Available      patients with diabetes a
      incorporates silicone are useful.         online at:                          few key factors need to
      Mepitel can be left in place to
                                                Kantor J, Margolis DJ (2007) Epidemiology.         be addressed, such as the
      allow uninterrupted wound                 In: Morison M, Moffatt CJ, Franks PJ,              exclusion of peripheral
      healing and only the secondary            eds. Leg Ulcers: A problem-based learning          ar terial occlusive disease,
      dressing renewed. The open                approach. Mosby, Elsevier, Edinburgh
                                                                                                   the assessment of
      texture of the dressing allows the        Kite A, Powell J (2007) Arterial ulcers:           peripheral neuropathy and
      wound to be inspected at each             theories of causation. In: Morison M,              the removal of calluses.
      dressing change                           Moffatt CJ, Franks PJ, eds. Leg Ulcers: A
8     Control of oedema is an essential         problem-based learning approach. Mosby,
      component of treatment. If there is       Elsevier, Edinburgh                              8 If the patient has
      no evident venous disease, reduced                                                           neuropathic foot
                                                Marshall C (2004) The ankle–brachial
      compression of < 25 mmHg may              pressure index. A critical appraisal. Br J         ulceration or evidence of
      be sufficient to remove oedema            Podiatry 7(4): 93–5                                haemorrhage beneath a
      and promote healing                                                                          callus, compression should
                                                Marston WA (2007) Leg ulcers associated
8     Patients with venous disease may          with arterial insufficiency : treatment. In:        not be applied without
      require high compression multi-           Morison M, Moffatt CJ, Franks PJ, eds. Leg         specialist advice.
                                                Ulcers: A problem-based learning approach.
      layer bandaging                           Mosby, Elsevier, Edinburgh
8     Particular care should be taken                                                           8 Compression therapy
      when applying compression to pad          Moffatt CJ, Franks PJ, Doherty DC, Martin         may be of some value
      the area of the tibial crest to avoid     R, Blewett R, Ross F (2004). Prevalence of        with rheumatoid ar thritis
                                                leg ulceration in a London population. Q J        because of the associated
      any excess of pressure to this            Med 97(7): 431–7
      vulnerable area                                                                             venous insufficiency.
8     In rare cases, if healing does not        Morison M, Moffatt CJ, Franks PJ (2007)           However, it may cause
      progress within a few months
                                                Leg Ulcers: A problem-based learning              excruciating pain in a small
                                                approach. Mosby, Elsevier, Edinburgh              percentage of patients.
      with conventional treatment, the
      patient should be referred to a           Mostbeck A, Partsch H, Peschl L (1977)
      plastic reconstructive surgeon for
                                                Alteration of blood volume distribution         8 Up to 70% of people with
                                                throughout the body resulting from                sickle cell anaemia are
      consideration of a skin graft. WUK        physical and pharmacological intervention.
                                                J Vasa 6(2): 137–42
                                                                                                  likely to develop a leg ulcer
This article was originally published                                                             (Serjeant, 2001) and these
                                                Oliver S, Mooney J (2002) Targeted                ulcers tend to be slow
in Compression Therapy in Practice,             therapies for patients with rheumatoid
edited by Christine Moffatt, published          arthritis. Prof Nurse 17(12): 716–20
                                                                                                  to heal and recurrence is
by Wounds UK. To buy a copy go to                                                                 common.
                                                Olujohungbe A, Anionwu EN (2007) Leg                   ulcers in sickle cell disorders. In: Morison
                                                                                                8 Care should be taken
                                                M, Moffatt CJ, Franks PJ, eds. Leg Ulcers:
                                                A problem-based learning approach. Mosby,         when considering using
References                                      Elsevier, Edinburgh                               compression therapy for
                                                                                                  patients who have had
Burns P, Gough S, Bradbury AW (2003)            Pun YLW, Barraclough DRE, Muirdue KD
Management of peripheral arterial disease       (1990) Leg ulcers in rheumatoid arthritis.        cardiac failure.
in primary care. Br Med J 326: 584–7            Med J Aust 153(10): 585–7
Cawley MI (1987) Vasculitis and ulceration      Ryan S (1995) Nutrition and the
in rheumatic diseases of the foot. Ballière’s   rheumatoid patient. Br J Nurs 4(3): 132–6
Clinical Rheumatology 1(2): 315–33
                                                Serjeant G (2001) A Guide to Sickle Cell
Chernoff AI, Shapleigh JB and Moore CV          Disease. A handbook for diagnosis and
(1954) Therapy of chronic ulceration of the     management. Sickle Cell Trust, Jamaica

 94      Wounds    UK,   2008, Vol 4, No 4