COMPRESSION THERAPY

FOCUS

Bandages and
bandaging techniques
for compression therapy
Alison Finnie
reatment for venous leg ulceration is cen- applied (Whitla, 1896). It was not known exactly

T
Alison Finnie is Lecturer,
Department of Nursing tred around the need to reverse venous why the treatment worked, but there was evidence of
and Midwifery,
University of Stirling
hypertension in the superficial veins in the symptom relief for patients suffering from oedema,
lower legs. The application of graduated compres- ‘heavy legs’ or varicose veins.
sion therapy forces fluid in the interstitial spaces Meta-analysis of randomised controlled studies as
back into the vascular and lymphatic systems. Since part of a Cochrane review (NHS Centre for Reviews
the pressure in the veins in an upright person is and Dissemination, 1997) has shown that the most
hydrostatic, the proximal pressure is generally less effective treatment for venous leg ulceration is com-
than the distal pressure. The external pressure need- pression applied by either stockings or bandages.
ed to achieve a therapeutic effect therefore becomes Stemmer (1969) calculated that an external pressure
progressively less from ankle to knee; this is called of 40mmHg was required at the ankle to reverse
graduated compression. If a bandage is applied at chronic venous hypertension and current compres-
the same tension, or stretch, along a limb, it would sion therapy usually aims to deliver this level of
be expected that the pressure applied by that ban- pressure at the ankle.
dage is less over a greater circumference than a Treatment failure may be due to inadequate or
smaller circumference. If this law (Laplace’s Law) inappropriate application of compression which may
is applied to the leg, and the ankle has a smaller cir- be due to patient intolerance, lack of compliance or
cumference than the calf, then an application of a understanding or to the health-care professional’s
bandage at the same tension along the leg, will nat- lack of knowledge and ability (Tennant et al, 1988).
urally give a graduated reduction in compression Applying the correct bandage using the correct
towards the knee. The greatest pressures will be at method is therefore vitally important. Any patients
the ankle, and the lesser pressure will be at the top considered for compression bandaging should
of the leg (Moffatt, 1992). have a full assessment, including Doppler exam-
Application of external pressures may be ination to exclude arterial insufficiency (Scottish
achieved by the use of elastic compression. Early Intercollegiate Guidelines Network (SIGN), 1998).
evidence of this treatment is available as far back as
1896 when Martin’s India-rubber bandage was Non-compression bandaging
Besides retaining dressings and supporting joints,
simple bandaging may be beneficial in patients with
ABSTRACT mixed aetiology, or significant arterial disease,
Bandaging skills are essential for community nurses not only as a where compression is inappropriate. Bandaging
method of supporting joints, or retaining a dressing, but as an can warm, insulate and protect a limb. Mitotic (cell
important treatment of leg ulceration. It is important to be able to division) activity, is essential for wound healing,
choose the correct type, size, and composition of bandage and as it is integral to the creation of collagen and
then apply it safely using the most appropriate technique as epithelial cells which are required for resolution of
incorrectly applied bandages may lead to pressure necrosis and ulcers. Mitotic activity is increased when surface
subsequent limb amputation. Bandaging applications have temperature is maintained at 37ºC (Lock, 1980).
changed little over the last 100 years and the two most commonly Therefore, the application of a padding layer fol-
used techniques are still the spiral and the figure-of-eight meth- lowed by a retention bandage such as a crepe may
ods. There are advantages and disadvantages of both, and suc- add warmth to the limb, as well as providing some
cessful bandaging depends on choosing the correct product, and protection from trauma, and therefore may improve
good technique, both in stretching the bandage to the correct healing rates.
tension, and ensuring proper overlap between layers. Compression bandages applied to venous leg
ulcers may also warm the wound bed by passive

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 COMPRESSION THERAPY
FOCUS

● Long stretch bandages are made of woven or

Table 1. Bandage widths knitted fibres and contain an elastomer such as
rubber. Some can be stretched up to 120%. The
Area to be fibres will yield and stretch with movement and
bandaged Width of bandage
recover tension without losing pressure
Fingers 2.5 cm ● Short stretch bandages contain no elastomeric
Hands 5 cm fibres. They depend on crimped threads for their
extensibility, which do not recover after stretch-
Arms 5–10 cm
ing. They may exert higher pressure when the
Lower legs 10–15 cm patient is upright and walking, and lower pres-
Thigh 15 cm sures at rest.
Stretch bandages can be further divided into smaller
Trunk 15 cm
groups:

thermal gain, as natural heat does not escape easily Light support
through the multiple layers. These provide minimal stretch and support and can
be used for dressing retention or as part of a layered
Types and classification compression system. Some contain elastomer fibres,
of bandages for compression others are simply crimped fibres.
Compression bandages are composed of different
materials, and are available in different lengths, Light compression
widths and strengths. Choosing the correct width of These provide and maintain low levels of compres-
bandage ensures smoother, simpler and safer appli- sion (Class 3a, 14–17mmHg at the ankle). They
cation. As a general rule, smaller bandages tend to can be applied in a spiral or figure-of-eight method
be used for smaller limbs (Table 1). and can be used as part of a layered system for
venous ulcers.
Padding layers
All bandages used in compression must be applied High compression bandages
on top of a padding, or ‘wool’ layer. This is used to These are much stronger bandages and provide and
prevent friction and pressure damage over bony maintain high levels of compression (Class3c,
prominences and pressure points by padding and 25–35mmHg at the ankle) at the ankle. Class 3c ban-
spreading the pressure across a greater area. This dages are useful for bigger legs or more active
layer is usually a 10cm roller bandage applied patients. They tend to be stronger, thicker bandages
without tension in a spiral next to the skin, or alter- and stretch further – up to 120%. They can be used
natively on top of a layer of thin loose cotton stock- over wadding on their own, or as part of a layered
ing for comfort as the ‘wool’ may itch. The system for venous ulceration. These should only be
padding can also be used in additional small pieces applied using a spiral technique, as other techniques
to provide extra protection for the shin, the ulcer may create greater pressures.
area, and the tendinous area on the dorsum of the
foot and to provide extra absorbency for an exud- Extra high compression
ing ulcer. The ‘wool’ layer evens out the contours These provide very high levels of compression
of the leg, especially around the troughs behind the (35–50mmHg) at the ankle and are grouped as a
malleoli allowing for smoother and more constant Class 3d. Unlike all those previously mentioned,
compression. A small ankle circumference of less these bandages cannot remain in situ for long peri-
than 18cm will require extra padding (Cameron, ods of time. They must be removed at night and re-
1996) as applying the same level of compression applied each morning, otherwise pressure damage
over a smaller surface area can generate greater can occur.
pressures directly onto these vulnerable surfaces. In addition to these roller bandages are two types
This padding layer can be reduced around the of adherent bandages:
underside of the foot to reduce bulk and to allow
footwear to be worn. Adhesive bandages
These provide light compression (14–27mmHg) and
Types of bandage are useful mostly as strapping for damaged joints.
Retention and compression bandages tend to fall However, these should be used with caution because
into two broad groupings: the adhesives used can cause skin reactions.

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 COMPRESSION THERAPY
FOCUS

Multilayer bandaging systems

Layers of bandage can be incrementally increased to
1 6 deliver greater pressure, as two layers of bandage
can provide twice as much pressure as one layer
(Nelson, 1997).
The four-layer method (Moffatt, 1992) became
available as a kit on drug tariff in December 1998,
and is possibly the most common method of applying
2 7 compression to venous leg ulcers. It consists of four
layers of bandage applied from the base of the toes to
knee, joint to joint, consisting of the following for a
normal (18–25cm diameter) ankle:
1. Layer of padding
2. Layer of crepe bandage
3. Layer of compression bandage (Class 3a)
3 8 4. Layer of cohesive bandage.
The bandages are usually 10cm in width and
approximately 3–5m long unstretched. They are
applied with a 50% overlap. This combination and
the overlap, aims to provide greater pressure at the
ankle (approximately 40mmHg), which is required
4 9 to reverse venous hypertension and 17mmHg at the
knee. The natural shape of the leg therefore helps
achieve the graduated pressure without the bandage
tension needing to vary. If the leg does not increase
in size toward the knee then the tension needs to be
reduced from the ankle to the calf to achieve the
graduated compression. The bandage tension
5 10 should always be relaxed slightly at the final wrap
at the knee to avoid a tourniquet effect.
The layer of crepe bandage is used to smooth and
compress the wool layer and increase its absorben-
cy. It is applied in a spiral. Smoothing the wool layer
allows more even application of the pressure-
producing bandages. This layer therefore preserves
Figure 1. Spiral Cohesive bandages the energy of the elastic bandages, as they are
technique (after These provide light compression (14–27mmHg) at not required to compress the – sometimes lumpy –
Moody, 1999).
the ankle. Cohesive bandages do not adhere to the primary layer.
skin or under padding, but only to themselves. They The third layer is a 10cm light elastic con-
are therefore useful as the outer layer in conjunction formable bandage applied at 50% stretch from toe
with other compression bandages, and are useful to to knee using a figure-of-eight technique with a
prevent slippage. 50% overlap. An extra layer may be required for
ankle circumferences over 25cm, or a higher com-
Short stretch/minimal stretch pression elastic bandage (Cameron, 1996).
These bandages have limited extensibility and Compression therapy can be uncomfortable when
should be applied at full stretch. They can be used in first applied. To reduce the initial compression
single or double layers, over padding, for treatment force, this layer may be applied in a spiral and then
of venous ulcers. They work by producing an inflex- upgraded to a figure-of-eight, once the patient
ible column of bandage against which the contrac- becomes used to the compression.
tion of the calf muscle compresses the leg veins, so The fourth and final layer is a lightweight elastic
are only really effective in those with full mobility. cohesive bandage applied at 50% stretch in a spiral.
They produce low resting pressures and can be used This additionally increases the compressive nature
over orthopaedic wadding for treatment of lym- of the multilayer system. The cohesive layer helps
phoedema. Spiral and figure-of-eight applications hold the bandages in place and prevents slippage,
can be used. adding durability to the system of bandages. As the

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 COMPRESSION THERAPY
FOCUS

bandage to do so with a consistent, usually 50%,

1 overlap.
Other bandages are also marked with rectangles
that change to squares when the bandage is
stretched to approximately 50%. For training pur-
poses, bandages without extension indicators can be
2 marked at 10cm intervals. Stretch can be noted by
the percentage increase between the interval marks.
For example, if the difference between the 10cm
marks is 15cm, then the bandage has been stretched
by 50%.
Consistent stretch and overlap reduces the risk of
3
uneven layers and subsequent oedema, or pressure or
friction damage.

Bandaging techniques
When applying any bandage the patient should be
4
in a comfortable position, which he/she is able to
sustain. The nurse should also be in comfortable
position to allow full access to the area requiring
to be bandaged. When applying a roller bandage
the roll should be held uppermost in the dominant
5 hand. A fixing turn should be made around the area
to be bandaged, and then the bandage should be
unrolled, at a steady tension, around the area.
Bandages should always be applied from a joint
to a joint, with lower limb bandages commencing
at the base of the toes and finishing just below
Figure 2. Figure-of-eight technique (after Finnie, the knee.
2001) There are three common methods of applying
bandage sticks to itself, adhesive tape should not bandages (Gundersen, 1992; Moody, 1999).
be required.
This system should ideally have the compression Spiral
sustained, so only weekly changes are performed. In The spiral bandage consists of taking a fixing turn,
meta-analysis, Fletcher at al (1997) demonstrated then taking simple oblique turns around the limb,
that the four-layer system is twice as likely to heal each turn ascending higher than the preceding one
an ulcer than a single-layer system. A layered sys- and overlapping it one-half or two-thirds (Henderson
tem may also be considered to be a safer method of and Taggart, 1978).
applying compression, since pressure increases Applications of spiral bandages with this tech-
gently as each layer is applied. nique are thought to provide a smoother more grad-
However, there are at least four layers of bandage uated compression, as the amount of overlap up the
used, and in addition there may be tubegauze, dress- leg is consistent (Figure 1). However, the spiral tech-
ings and outer layers of elasticated tube stocking nique is more prone to slippage than other methods.
creating a bulky therapy. Patients have reported
finding the treatment comfortable, but also com- Figure-of-eight
plain that it can be heavy and hot to wear (Roe et al, The figure-of-eight bandage consists of oblique
1995). Reducing the number of layers and using a turns that alternately ascend and descend after encir-
different combination of bandages may be more cling the part. Each turn crosses the preceding one in
appropriate for some patients. front, making a figure-of-eight, and overlaps it one-
half or two-thirds (Henderson and Taggart, 1978). If
Application bandaging a leg, the bandage starts with a fixing
Some bandages are supplied with indicator marks turn at the base of the toes and is applied in a spiral
to aid application, such as a coloured line running around the foot. The bandage is then carried upward
longitudinally along the middle of the bandage. across the front of the limb at 45º, round behind the
This central line assists the person applying the leg at the same level and then downwards over the

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 front of the limb to cross the bandage at a right
angle. The turns are repeated, ascending the limb
1 7
until it is covered (Figure 2).
This bandage may stay in place more effectively
and is useful for larger limbs, or over active muscles,
or where the limb is unusually shaped, e.g. the
inverted champagne-bottle shape characteristic of
venous disease. The figure-of-eight technique tends
to slip less than a spiral and also allows a greater 2 8
degree of compression.

Pütter
In addition, there is another method called the Pütter
(sometimes described as the puttee or putta) method.
This is far less common, and tends to be used only
3 9
with short-stretch bandages (Moody, 1999). With
this method the bandage is wrapped around the leg
upwards and then wrapped downward filling in any
‘soft’ spots (Figure 3).
It should always be possible, with any technique,
to insert two fingers in the top and bottom of the
bandage, to check that the bandage is not too tight. 4 10
Despite the small number of standard tech-
niques, it is clear that bandage application is depen-
dent on the applicator and no two bandages are
applied in exactly the same way (Holford, 1977;
Williams et al, 1999). Clear documentation to
allow consistent management, as well as effective
5 11
skills training is important for any nurse managing
patients with leg ulcers.

Hazards of compression bandaging

Incorrectly applied compression bandages may
lead to pressure necrosis and subsequent limb
amputation (Callam et al, 1987). Damage can result 6 12
from incorrect choice of bandage, lack of padding
layers, and poor bandaging technique. Given the
variety of possible disease stages it is not clear
exactly how much pressure may cause damage.
Holstein et al (1979) found that external pressure
could be applied that easily compressed the micro-
circulation in the venous end of capillaries with low bony prominences such as the sacrum. In the legs, Figure 3. Pütter
intravascular pressures (4–25mmHg). However this is likely to be the tibia, the Achilles tendon, the technique (after
Moody, 1999).
skin circulation was maintained at greater external dorsum of the foot, and the malleoli. Damage can be
pressures, and only if external pressure was greater related to prolonged loading or compression, even
than the diastolic arterial blood pressure did while at low pressures.
ischaemia occur. Generally compression bandages Limbs should be checked 24 hours after a ban-
are not intended to apply pressures greater than dage has been applied for the first time – the ban-
approximately 40mmHg. dage should be removed and the condition of the
Bader (1990) examined the recovery characteris- skin checked for any ridging, redness, or discol-
tics of soft tissue relating to pressure ulcer forma- oration. Patients, to whom bandages have been
tion. The principle of pressure damage caused by applied should be advised to check for any swelling
bandages is similar to pressure damage resulting of the toes, sensation of ‘pins and needles’, unnat-
from immobility in a bed or chair, where areas at urally cold extremities, and a change in skin colour
particular risk have minimal soft tissue covering to white or blue. Great care should be taken with

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 COMPRESSION THERAPY
FOCUS

patients with diabetes, neuropathy or any sensory

impairment who may be unable to detect whether
KEY POINTS bandages are causing any pain or discomfort.
● The most effective treatment for
venous leg ulceration is compression Conclusion
applied by either stockings or Leg ulceration, once regarded as a chronic recur-
bandages. ring or non-healing condition, can now be expect-
● Applying the correct bandage using ed to progress to full healing with the application
the correct method is vitally of compression therapy. However, it is still not
important known which compression system, and method of
● There are three common methods of application is the most effective treatment for
applying bandages: the spiral, the venous leg ulceration; studies are ongoing. Choice
figure of eight and the pütter of compression bandage and bandaging technique
techniques. should therefore depend on a thorough assessment
of the patient, the practitioner’s knowledge, and
● Incorrectly applied compression
patient choice. ■
bandages may lead to pressure
necrosis and subsequent limb
amputation and damage can result Bader DL (1990) The recovery characteristics of soft tissues
from incorrect choice of bandage, following repeated loading. J Rehabil Res Dev 27(2):
141–50
lack of padding layers, and poor Callam MJ, Ruckley CV, Dale JJ, Harper DR (1987)
bandaging technique. Hazards of compression treatment of the leg: an estimate
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Cameron J (1996) Venous leg ulcers. Nurs Stand 10(25):
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Finnie A (2001) Management of venous leg ulcers by com-
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Fletcher A, Cullum N, Sheldon TA (1997) A systematic
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Henderson V, Taggart E (1978) Application of surgical
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Holstein P, Nielsen PE, Barras JP (1979) Blood flow cessa-
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Lock PM (1980) The effects of temperature on mitotic
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Stemmer R (1969) Ambulatory-elasto-compressive treat-
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stockings. Der Kassenatzt 9: 1–8
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