Leg ulcers are treated by different forms of dressings by the family physicians. It is extremely important to know what the cause for the ulcer is? 80% 0f the ulcers in the legs are due to vascular insufficiency. Healing and preventing recurrences can only be achieved by correcting the vascular cause. Dressings do play an important role in aiding ulcer healing.

Venous Ulcer

Before	After

Aetiology

	Venous 75%
	Arterial 22%
	Rheumatoid arth 12%
	Diabetes 05%
	Multifactorial 15%

Causes of Venous Ulcers

	Calf pump failure
	Calf muscle disuse
	Peripheral neuropathy
	Orthopaedic disorder etc
	Out flow obstruction
	Pregnancy, obesity, tumours & DVT
	Incompetent valves
	Superficial, deep, communicating veins

Pathophysiology of Venous Ulcer

	Increased cap/venous pressure
	Leakage of fibrinogen into interstitial spaces
	Formation of pericapillary fibrin layer
	White cell trapping theory
	Anoxia and Malnutrition
	Accelarated by trauma

Initial Assessment

	History & Clinical examination
	Hand held Doppler
	Colour Doppler scan
	Ankle-Brachial index

Treatment of Venous Ulcer

	Topical treatment
	Four layer compression bandaging
	Corrective venous surgery
	Maintenance treatment

Dressings

Following extensive randomised controlled studies, involving different dressing types used in conjunction with the four layer bandage, it was found that dressings had little influence on ulcer healing.
Therefore, a simple low adherent dressing such as Sofratule, Inadine is used

Four layer Compression Bandaging

Graduated Compression Has Shown to

	Increase blood velocity in the deep veins
	Reduce oedema and therefore reduce pressure differential between the capillaries and the tissues.
	Reduce distention of the superficial veins and reverse venous hypertension.
	Improve the healing rate of chronic venous ulcers.

Stemmer et al

	Demonstrated that 40 mm Hg pressure is required at the ankle to reverse chronic venous hypertension.
	The four layer bandage system is developed to apply 40 mm Hg pressure at the ankle graduated to 17 mm Hg at the knee using bandages of differing properties.

All bandages used are 10 cms. in width and should be applied from the base of the toes to the knee joint.

Layer I
Orthopaedic wool:

	This is used to absorb exudate and redistribute pressure around the ankle, protecting the bony prominences from excessive pressure.
	It also fills in the troughs behind the malleoli where little pressure is exerted.
	The bandage is applied without tension in a loose spiral.

Layer II
Cotton crepe:

	Its main function is to increase absorbency and to smoothen the orthopaedic wool layer, thereby preserving the elastic energy of the main compression layers.
	The crepe is also applied in a spiral.

Layer III
Elasticated crepe:

	This is the most important layer achieving compression.
	It is applied at mid-stretch in a figure of eight with a 50% overlap.

Layer IV
Coban:

	It is a lightweight, elastic, cohesive bandage.
	It maintains the four layers in place and adds durability to the system.
	It is applied at mid-stretch with a 50% overlap.

Contraindication

	Peripheral vascular disease.
	Oedema secondary to heart failure.
	Thin calves and narrow ankles
	Rheumatoid arthritis and Diabetes mellitus.