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Four-layer bandaging: from concept to practice Part 2: Application of the four-layer system

Author(s)

Christine Moffatt
PhD, MA, RGN, DN
Professor of Nursing and Co-director of the Centre for Research and Implementation of Clinical Practice
Thames Valley University, London, UK.
Email: christine.moffatt@tvu.ac.uk

Contents
Published: Mar 2005
Last updated: Mar 2005
Revision: 1.0

Keywords: compression bandaging; venous ulceration; clinical indications; bandage application; wound healing.

Key Points

  1. All decisions regarding the application of compression bandaging require a full patient assessment.

  2. There is a clear need for appropriate training in the art of bandaging as well as an understanding of the scientific principles of compression.

  3. The application of the four-layer system can be modified to suit individual patient groups.

Abstract

Four-layer bandaging has been in existence for more than 15 years, during which time it has been used in numerous studies and in many populations throughout the world. This short series reviews the development of the four-layer compression bandage system together with the evidence that contributes to a greater understanding of why it is effective in promoting healing in venous leg ulcers. This article, the second in the series, looks at the clinical indications for use and how to apply a four-layer bandage.


Introduction

Four-layer bandaging is a high-compression bandaging system (sub-bandage pressure 35-40mmHg at the ankle) that incorporates elastic layers to achieve a sustained level of compression over time. Since the development of the four-layer system over 15 years ago, compression therapy has become widely accepted as the cornerstone of venous leg ulcer treatment.

Clinical indications for use

The four-layer bandage system is primarily used in the treatment of venous ulceration and achieves healing in patients with both deep, superficial and combined venous incompetence [1],[2],[3]. Four-layer bandaging can also be used to prevent recurrence in patients who are unable to wear elastic hosiery. Vulnerable patients with conditions such as Alzheimer's disease have been managed successfully in this way with the bandage changed every 1-2 weeks.

There is increasing clinical experience of using four-layer bandaging in patients with venous lymphatic disorders. The short-stretch, inelastic effect noted in four-layer bandaging has made this a useful treatment option, although modifications to the application are required. Further indications for the use of four-layer bandaging include conditions where oedema hinders wound healing, such as pretibial lacerations (Box 1).

During the early stages of the development of the four-layer bandage, alterations to the system were made so that reduced levels of compression could be applied to patients with mixed aetiology ulceration (those with both venous hypertension and mild to moderate arterial disease) [4]. Further research is required to examine the most effective methods of treating these patients. However, reduced or light compression using three-layer bandaging (with sub-bandage pressure 17-25mmHg), omitting one elastic layer, has been used with encouraging results in a number of studies [2]. Current recommendations suggest that a Doppler ankle brachial pressure index (ABPI) is a useful guide to aid decisions concerning compression and to exclude patients with significant arterial disease (Box 2). According to the RCN Institute's clinical guidelines [5] and the International Leg Ulcer Advisory Board recommendations [6], an APBI greater than 0.8 usually indicates venous ulcers, with arterial involvement suggested by an APBI of less than 0.8. Mixed venous/arterial ulcers may have an APBI of 0.5-0.8. Although compression is not usually recommended with an APBI of lower than 0.8, it has been used successfully in patients with an APBI as low as 0.5 [5].

No decisions regarding the application of compression should be made without a full patient assessment [6]. Ankle brachial pressure readings, while highly reproducible, require accurate technique and careful interpretation of the findings, including an understanding of the significance of altered wave forms and the impact of vascular calcification on systolic pressures. Assessment must therefore take account of the presenting signs and symptoms, such as intermittent claudication, rest pain and signs of poor distal perfusion. The degree of severity and distribution of arterial disease requires more complex evaluation using Duplex ultrasonography and angiography.

Contraindications

There are few absolute contraindications to the use of high compression [8], although failure to identify arterial disease will result in the unsafe application of this therapy. All patients must be individually assessed for risk.

Patients with decompensated heart failure should not receive high-compression therapy. In this instance high compression will redistribute blood towards the centre of the body, thereby increasing the pre-load of the heart and possibly causing further overload and death [9].

In addition, patients with severe obliterative arteriosclerosis (for example with an ABPI <0.5) should not receive compression therapy.

For patients with mixed aetiology ulceration who undergo reconstructive surgery there is growing anecdotal evidence that, providing there is adequate perfusion following surgery, venous hypertension can be managed safely with compression. However, careful supervision and monitoring of the therapy is required as any change in symptoms may indicate relapsing arterial disease. If this occurs the compression bandages must be removed immediately and urgent vascular assessment sought.

Patients with diabetes mellitus are often prevented from receiving compression therapy. However, a diagnosis of diabetes should not preclude treatment with compression and it is essential that the correct cause and underlying aetiology of the ulcer is established. Compression should be used with caution in patients with peripheral neuropathy as they will not be aware of pressure-induced tissue damage.

Patients with rheumatoid arthritis often have venous disease, with an increased rate of venous refilling [10], poor ankle movement and reduced calf muscle-pump function. The protective function of four-layer bandaging can be helpful in such patients, particularly those who are highly susceptible to skin trauma as a result of dermal thinning due to the regular use of corticosteroids and those who have dependency oedema. Compression should be avoided in the small percentage of patients with vasculitic ulceration as this will exacerbate the failing microcirculation and can lead to extensive tissue necrosis [11].

Application of four-layer bandaging

A number of factors should be addressed before the application of four-layer bandaging (Box 3).

The methods used to apply four-layer bandaging have been described in numerous publications [17],[18]. However, in reviewing the concepts underpinning the system it is important to examine the rationale for how the bandage should be applied and its adaptation for individual patient groups. Table 1 outlines the application issues relating to four-layer bandaging systems.

Table 1: Application of four-layer bandaging (ankle circumference 18-25cm)
Bandage Function Bandage characteristics Foot Ankle Limb Modifications Comments
Orthopaedic wool  Absorbs exudate.

Redistributes pressure around limb 

Orthopaedic wool with varying levels of conformability and compressed thickness  Apply padding to base of toes. Pad tender area over dorsum of foot  Ensure achilles tendon well covered  Ensure even application of 2 layers of padding  Use extra padding to protect bony prominences. Recontour limb with loss of calf muscle. Avoid excessive padding which reduces pressure  Density and conformability of different products varies. Extra pad of foam over post malleolar area useful to increase pressure over ulcerated areas 
Cotton crepe  Adds absorbency. Smooths orthopaedic wool.

Preserves elastic energy (no compression) 

Light support bandage. Unable to apply high levels of compression. Least effective layer  Bandage from base of toes using tension to ensure smooth surface on which to apply elastic layers  Cover all padding to avoid excessive bulk  Continue with 50% overlap up the limb  Second bandage not required unless excessively tall patient  Some 4 layer systems incorporate bandages with elastomeric fibres which may offer higher levels of pressure than cotton- based products. Check bandage specification 
Elastic, extensible bandage  First layer of elastic compression sub-bandage (pressure at ankle 17mmHg)  Light compression able to apply and maintain pressures up to approx. 20mmHg on ankle circumference (18-25cm)  Begin extension from base of toes with 2 anchoring turns at 50% extension  Apply figure of 8 using a high and then low turn to avoid excess layers over dorsum of foot  Apply in a figure of 8 with 50% extension and overlap  Reduced pressure can be achieved by applying bandage in a spiral. Increased overlap will increase the pressure  Bandage extensibility ranges considerably within this group 
Cohesive bandage  Second layer of compression adds remaining 23mmHg of pressure. Cohesiveness retains bandage position  Cohesive, elastic bandage able to apply pressures up to approx. 25mmHg on ankle circumference (18-25 cm)  Applied in a spiral  Apply figure of 8 around ankle with a high and low turn. Avoid over- extension at front of foot  Bandage using 50% extension. 50% overlap using spiral technique  In 'champagne' shaped limbs with increased diameter use figure of 8 technique. This can increase pressure and prevent slippage  Variations in extension possible.

Non-latex cohesive used in some systems 

The careful design of the original Charing Cross four-layer and the newer Profore systems were based on a thorough knowledge of the compression profiles of each bandage and of their combined effects. Although a number of multi-layer systems are described in the literature, it cannot be assumed that any combination of bandaging constitutes a four-layer system equivalent to the Charing Cross system. High compression bandages are available which, when used alone, can produce clinically effective levels of pressure, 35-40mmHg at the ankle. These bandages can, however, produce dangerously high levels of compression (>80mmHg) when used inappropriately[19].

Application over the foot

There is debate over whether elastic bandages should be applied at tension (force applied to fabric) over the foot. In the four-layer system, the elastic layers are applied with tension from the base of the toes. Failure to apply tension, and therefore equivalent pressure, over the foot can result in the rapid accumulation of oedema over the dorsum of the foot. However, this may create a tourniquet effect around the ankle when extension is applied. Excessive pressure should be avoided and precautions must be taken in patients who are underweight or who have orthopaedic foot deformities such as hallux valgus (bunion). Many patients develop lymphoedematous changes of the toes. This can be managed by bandaging the toes with a light, mildly extensible cotton bandage.

Layer 1: orthopaedic wool: Orthopaedic wool provides a layer of padding that protects areas at risk of high pressure, such as the foot and ankle. Bandage slippage and pressure can result in damage to the Achilles tendon so this area must be well protected. The tibial crest is often subjected to high levels of pressure, with evidence of pressure damage on bandage removal. Patients with thin limbs are particularly vulnerable, as are men with a prominent tibial crest and little overlying subcutaneous tissue. Simple methods such as pleating the orthopaedic wool or the addition of a strip of wool over the area can provide extra protection. Due to the increased skin sensitivity in venous disease, the padding layer should cover all vulnerable areas and just be visible at the toes and top of the bandage.

The addition of a light cotton tubular bandage next to the skin may also offer protection to patients who are prone to varicose eczema.

Layer 2: crepe bandage: This is the least effective layer as it simply adds extra absorbency and smooths down the orthopaedic layer prior to the application of the two outer compression bandages.

Layer 3: elastic extensible bandage: This is the first of the two outer elastic bandages. It is a highly extensible bandage that provides a sub-bandage pressure of approximately 17mmHg when applied at 50% extension with a 50% overlap using a figure-of-eight technique. In 'champagne' shaped limbs the figure-of-eight application can be widened to aid conformability. If greater pressure is required over an oedematous calf, this can be achieved in the following ways:

Similarly, in patients with thin limbs the pressure can be reduced by decreasing bandage extension. The wide extensibility curve (ability to stretch) in these bandages allows for flexibility on application, but again practitioners must take care not to decrease the pressure to an ineffective level.

Layer 4: elastic cohesive bandage: A frequent misconception is that the outer cohesive layer within the four-layer system is there simply to maintain the bandage position. In fact, this layer provides the higher level of compression (sub-bandage pressure approximately 23mmHg) and must not be over-extended. Bandaging should extend over the upper portion of the gastrocnemius muscle to prevent slippage. The cohesive layer should not be applied in direct contact with the skin because of the risk of latex allergy. Some systems incorporate a latex-free outer layer. The two outer elastic bandages, when used in combination, provide a sub-bandage pressure of approximately 40mmHg.

Modifying the four-layer bandage system

The pressure generated by a bandage is determined principally by the tension in the fabric, the number of layers applied and the degree of curvature of the limb. The relationship between these factors is governed by Laplace's law[20], which states that the applied pressure is directly proportional to the tension in the bandage but inversely proportional to the radius of the curvature of the limb to which it is applied. The natural cone shape of the lower limb is therefore a major factor in achieving a correct pressure gradient [21]. Where the patient's ankle circumference or limb shape is outside the normal range, modifications can be made to the system to achieve adequate sub-bandage pressures (Table 2). Thin limbs with a circumference of less than 18cm require additional padding to increase protection and artificially increase the circumference of the limb. In cases where the ankle circumference is greater than 25cm, a therapeutic level of compression is rarely achieved. In these patients, the elastic bandages are substituted for those with a higher elastic modulas (power). Care should be taken with these bandages to ensure correct bandage extension, using bandage application guides or symbols, when present, to aid this process. The patient's limb should be regularly measured as rapid loss of oedema may occur in the first few weeks of treatment, reducing the ankle circumference.

Table 2: Modifications to the four-layer bandage system based on ankle circumference (sub-bandage pressure of approximately 40mmHg applied to all limbs)
Ankle circumference less than 18cm 

2 or more orthopaedic wool

1 crepe

1 elastic conformable

1 elastic cohesive 

Ankle circumference 18-25cm 

1 orthopaedic wool

1 crepe

1 elastic conformable

1 elastic cohesive 

Ankle circumference 25-30cm 

1 orthopaedic wool

1 high compression bandage (approximate pressure 35mmHg*)

1 elastic cohesive 

Ankle circumference >30cm 

1 orthopaedic wool

1 elastic conformable

1 high compression bandage (approximate pressure 35mmHg*)

1 elastic cohesive 

* Increase in ankle circumference reduces sub-bandage pressure applied.

Reproducibility of graduated compression profiles

Evidence accumulated over the past decade suggests that there are wide variations in the gradient and level of compression applied by different bandages. This is despite simplistic classifications describing their use [22]. In addition, individual practitioners may produce very different compression profiles when bandaging the same patient using the same bandage technique but with different products [23]. This reinforces the need for appropriate training in the art of bandaging as well as an understanding of the scientific principles [24].

During the development stage of the four-layer bandage, extensive pressure monitoring studies revealed the system's ability to maintain pressure over time and that the pressures achieved were highly reproducible in a range of patients using different methods of application [17]. This compared starkly with the bandages in use at the time, such as elastocrepe and elastoplast, which had reduced sub-bandage pressures within a few hours that fell below a therapeutic level.

Research has begun to examine the dynamic effects of compression during exercise and in different limb positions [25]. These issues may be important in examining how compression works in complex patient populations. A number of authors have demonstrated that fluctuations in pressure occur during exercise [26]. Partsch noted that four-layer bandaging was associated with a rise in pressure of up to 45mmHg during walking, but at rest the pressure did not fall below 40mmHg [2].

A study comparing two multi-layer bandage systems found that variations in pressure were related to the position in which the patient was bandaged [27]. Those bandaged in a sitting position with a 90 degree angle at the knee had accurate gradients of pressure, compared with those bandaged in a semi-recumbent position where the calf pressure fell when the patient changed to a sitting position. This is probably due to changes in the calf circumference during contraction and relaxation of the calf muscle. The pressures at the knee and ankle were similar to those achieved in the semi-recumbent position.

While of interest, it remains unclear whether minor variations in sub-bandage pressure associated with changes in position are of clinical importance [28]. The issue is further complicated by the difficulties associated with pressure measurement and the variations between different application techniques [29].

Summary

It is important to fully assess patients prior to the application of four-layer bandaging. This will confirm the presence of venous disease and suitability for treatment; failure to identify arterial disease will result in the unsafe application of compression therapy. To achieve optimum levels of compression, practitioners require appropriate training, an understanding of the method of application and how this can be modified to suit individual patient groups.

References

1. Partsch H. Compression therapy of the legs. A review. J Dermatol Surg Oncol 1991; 17(10): 799-805.

2. Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages. Dermatol Surg 1999; 25(9): 695-700.

3. Partsch H. Dermal lymphangiopathy in chronic venous incompetence. In: Bollinger A, Partsch H, Wolfe JHN, editors. The Initial Lymphatics. New York: Thieme Stratton, 1985; 219-31.

4. Moffatt CJ, Franks PJ, Oldroyd M, Bosanquet N, Brown P, Greenhalgh RM, et al. Community clinics for leg ulcers and impact on healing. BMJ 1992; 305(6866): 1389-92.

5. RCN Institute, Centre for Evidence-Based Nursing, University of York, School of Nursing, Midwifery and Health Visiting, University of Manchester. Clinical practice guidelines: the management of patients with venous leg ulcers. London: RCN Institute, 1998.

6. Marston W, Vowden K. Compression therapy: a guide to safe practice. In: Understanding compression therapy: EWMA Position document. London: MEP Ltd, 2003; 11-17.

7. Scottish Intercollegiate Guidelines Network. The Care of Patients with Chronic Leg Ulcer: a national clinical guideline. Edinburgh: SIGN Publications, 1998; no. 26.

8. Moffatt CJ, O'Hare L. Venous leg ulceration: treatment by high compression bandaging. Ostomy Wound Manage 1995; 41(4): 16-8, 20, 22-5.

9. Partsch H. Understanding the pathophysiological effects of compression. In: Understanding compression therapy. EWMA Position document. London: MEP Ltd, 2003; 2-4.

10. Ruckley CV, Fowkes FGR, Bradbury AW. Venous Disease: Epidemiology, management and delivery of care. London: Springer-Verlag, 1999.

11. Pun YL, Barraclough DR, Muirden KD. Leg ulcers in rheumatoid arthritis. Med J Aust 1990; 153(10): 585-7.

12. Hollinworth H. Nurses' assessment and management of pain at wound dressing changes. J Wound Care 1995; 4(2): 77-83.

13. Franks PJ, Moffatt CJ, Connolly M, Bosanquet M, Oldroyd M, Greenhalgh RM, et al. Community leg ulcer clinics: effect on quality of life. Phlébologie 1994; 9: 83-86.

14. Franks PJ, Moffatt CJ. Who suffers most from leg ulceration? J Wound Care 1998; 7(8): 383-5.

15. Morison M, Moffatt CJ. Color Guide to the Nursing Management of Leg Ulcers (2nd edition). London: Mosby, 1994.

16. Muir-Gray JA. Social aspects of peripheral vascular disease in the elderly. In: McCarthy ST, editor. Peripheral Vascular Disease in the Elderly. London: Churchill Livingstone, 1983; 191-199.

17. Blair SD, Wright DD, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. BMJ 1988; 297(6657): 1159-61.

18. Moffatt C, Stubbings N. The Charing Cross approach to leg ulcers. Nurs Stand Spec Suppl 1990; 12(10): 6-9.

19. Thomas S. An evaluation of a new type of compression bandaging system. World Wide Wounds 2003; available from URL: http://www.worldwidewounds.com/2003/september/Thomas/New-Compression-Bandages.html.

20. Thomas S. The use of the Laplace equation in the calculation of sub-bandage pressure. World Wide Wounds 2003; available from URL: http://www.worldwidewounds.com/2003/june/Thomas/Laplace-Bandages.html.

21. Moffatt CJ. Compression bandaging - the state of the art. J Wound Care 1992; 1(1): 45-50.

22. Stockport JC, Groarke L, Ellison DA, McCollum C. Single-layer and multilayer bandaging in the treatment of venous leg ulcers. J Wound Care 1997; 66(10): 485-488.

23. Nelson EA, Ruckley CV, Barbenel JC. Improvements in bandaging technique following training. J Wound Care 1995; 4(4): 181-84.

24. Taylor AD, Taylor RJ, Said SS. Using a bandage pressure monitor as an aid in improving bandaging skills. J Wound Care 1998; 7(3): 131-3.

25. Partsch H, Mezinger G, Blazek V. Static and dynamic measurement of compression pressure. In: Blazek V, Schultz-Ehrenburg U, editors. Frontiers in computer-aided visualization of vascular functions. Aachen: Verlag, 1997; 145-152.

26. Veraart JCJM, Daamen E, Neumann HAM. Short-stretch versus elastic bandages: effective time and walking. Phlébologie 1997; 26: 19-24.

27. Taylor AD, Taylor RJ. A comparison of sub-bandage pressures produced with two multi-layer bandaging systems. J Wound Care 1999; 8(9): 444-8.

28. Veraart JCMJ, Neumann HAM. Interface pressure measurements underneath elastic and non-elastic bandages. Phlébologie 1996; 11(Suppl 1): S2-S5.

29. Clark M. Compression bandages: principles and definitions. In: Understanding compression therapy. EWMA Position document. London: MEP, 2003; 5-7.




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