Dr. Joel Aronowitz — Wound Care Multilayer Compression Wrap Dressing Tutorial
Dr. Joel Aronowitz: “Alright, so we just covered how to do an uniboot for compression therapy. Sometimes, uniboots are not indicated, and you need to do a different type of compression therapy. So, this is a different version. It’s a three-layer compression with ACE bandages. You can also do a three-layer with a co-band; you can do a four-layer compression. It’s all dependent on A, your patient; you want to make it patient-specific, and then also included in that is their diagnosis and what’s most appropriate for their treatment protocol. Some people need that extra level of compression. Some people can’t tolerate the ACE compression, or they can’t tolerate the co-band, or they’re heavy, heavy exudators, and the co-band doesn’t breathe enough, or they can’t tolerate uniboots because their skin is too friable or too delicate, and you don’t want to run the risk of worsening things with the uniboot if you don’t have the appropriate technique put on. So, we’ll cover today the three-layer compression with the ACE bandages that provides benefits. You can tailor the amount of compression by how much tension you put across the ACE bandages as you come around the leg, and you can use it for wound care to help with compression, force out that edema, and allow the wound margins not to be as stressed from the interior pressure from the interstitial fluid. You can use it for sports medicine applications, ankle sprains, tendonitis, any sort of support through the soft tissues can be more comforting to the patient, but a lot of our applications will be for wound care.
One of two layers you can start with is either the Curlex, which is more of the coarse, remember it is coarser Curlex, and the cast padding, which is the softer material here. I usually tend to start with the cast padding, just because it’s softer to the skin, it’s less abrasive. Curlex has been fine to use, and you’ll notice it’s used a lot in different applications of things, but one thing to be very mindful of is that it can be much more difficult on the skin if you have a patient with peripheral arterial disease or something like that; you can get a lot of friction, especially if the joints are on the bony prominences, and those can actually lead to wounds. I’ve seen it with nurses in the hospitals that either don’t have other materials to use or just don’t know the different applications of things. So, you can either check with your provider or just be mindful of the types of dressings, because not all materials are made the same, obviously. What we’ll do is we’ll start with this cast padding layer, and we’re going to say that our patient here has a wound on her medial ankle, a venous stasis wound, and therefore, we’re going to go from the toes all the way to the tibial tuberosity to allow for that whole right lower extremity compression. If you were just to say, go do the compression just above the wound, then you’re going to get a lot of increased edema just proximal to that dressing, and you’re not really going to be benefiting the patient substantially. My technique is to go wrap up and into the arch, and that’s really just for patient comfort. One thing you want to be mindful of is, it’s always easier to do a dressing when you have, I call it, the snail technique.
So, if you look at this, it’s kind of a snail; here’s the, so you always want the shell on top. If your shell is on bottom, it won’t wrap as easily, and you’re going to struggle and struggle and struggle, and be like, well, how do they make it look so easy, so remember your snail technique with the shell on top, okay? You wrap your metatarsal heads, make sure to capture those, try not to make any wrinkles because those can be uncomfortable for the patient as they’re walking, even if they’re on weight bearing, and you have them in a cam boot, per se, come up and around. Some people struggle with ankle joints getting the dressing to sit right; on this, really what I can recommend is coming into the arch, just right on the heel, and then following up and around that lateral ankle, and you’ll be able to capture that heel on your next turn or your next pass of the snail. So, come down and around; here, I’ll have my assistant hold right underneath the knee here, and then I come right underneath, and we’re able to fully capture that heel, and then it sets you up and capture this little tongue here, and then you’re set up to go up the leg. So again, you can put some compression through this, but the material is not going to provide a lot. The biggest thing is, 50% of coverage across every layer of the dressing, you could do the herringbone technique, which is that around and up and around and down technique, depending on the amount of compression you want through your dressing, and then you go to your next layer, Curlex. And you see, I am going down and into the arch, so something I catch myself on even, but you can always restart, and you just want to make sure that your patients are comfortable. And it wouldn’t be detrimental to do it that way, but might as well do it right. Come down, capture that heel there, and then you’re able to come up 50%, 50%, 50%, 50%, right under this tibial tuberosity, which is your bony landmark up here.
Contraindications for this would be if your patient had an acute DVT; obviously, you don’t want to put on a bunch of compression and dislodge that DVT. So here we have, again, the snail, the head of the snail here, and the shell up top here. So with this one, I am going to use the 4-inch Ace bandage. Sometimes you can have a double 6-inch or a 6-inch; 4-inch is easiest for the foot and the ankle. You can use a 6-inch for the calves, or you can use double 4s. This is where you’re going to get most of your compression, so I usually cuff the forefoot once, and then come up and around that ankle, and then around and up, around and down, around and up, around and down, around and up, around and down. You get this nice herringbone pattern on this, and if you have a patient who has a pretty large leg or has someone like an NFL player, or has really large, long tibia, as you might need two of these Ace bandages. You can see that ours fell short a little bit, and I want that compression up here, so I am going to use that second Ace bandage. Typically, you’re going to use about two if you’re going from the foot to the ankle. If you don’t have an awesome assistant like Trey here, one thing you can do is use your 6-pack abs, balance your patient right here, make sure they’re comfortable, and start right where you left off, and round and up, round and down. And you can either follow this back down if your patient is not at risk of having too much compression, and then just tape it. I never use the little metal prongs because those have been known to cause wounds as well. So if you have an awesome assistant, they’ll be ready with the tape, and with the tape, you want to tape the two corners here and here, and then one in the middle, so that you can see if the corners aren’t taped, it’s going to pull, and you want to make sure that it stays nice and well compressed.
Ideally, your partner would have your tape cut for you, but that’s okay, sometimes you have to do things on your own, and that is how I would expect the Ace bandage to be taped, is both corners so that you’re not getting any pull back there, and then check in with your patient, make sure that you have enough; you can fit two fingers or two-finger compression there, make sure that they still have pulses in their capillary refill time in their toes, and make sure they’re comfortable.”
Originally published at https://drjoelaronowitzmd.blogspot.com on January 4, 2024.
