Code:
[HIDE][/HIDE]
Structure
9.1 Definition
9.2 Types
9.2.1 Venous ulcers
9.2.2 Arterial (ischaemic) ulcers
9.2.3 Pressure sores
9.3 Lymphoedema
9.4 Scar tissue


9.1 Definition

An ulcer is a loss of epithelial cells causing exposure of the underlying tissue.

9.2 Types

1) Venous.
2) Arterial (ischaemic).
3) Pressure sores.

9.2.1 Venous ulcers

Aetiology

Sex - Women more than men.
Age - Most common in 50-70 year age group.

Site - Lower two-thirds of the lower leg (slightly higher on the anterior and medial aspects) and on parts of the foot not supported by the shoe.

Size - This varies but 18-20 cm2 on the lower leg is quite common. In some cases an ulcer can become very large and encircle the leg.

Predisposing factors

1. Venous and lymphatic congestion associated with varicose veins or deep venous thrombosis.
2. Occupations demanding prolonged standing.
3. Poor personal hygiene and malnutrition.

Precipitating factors

Local trauma - often very slight breaks the weakened skin.

Pathology

Due to failure of the venous pump as a result of valve incompetence, binding down of deep fibrous tissue, and lack of pumping action by the calf muscles there is chronic venous congestion. This results in increased exudate and slowing down of the blood flow. Nutrition of the tissues is diminished and the skin is devitalized. The cells necrose and the skin breaks down. There is insufficient oxygen and nutrition to promote healing and the area remains open. Bacteria may invade the area or the dead cells may irritate the normal tissue, causing inflammation and the ulcer spreads. If the chronic venous congestion is reduced and the circulation, bringing oxygen and nutrition to the area, is improved together with the removal of any infection and the mobilizing of the soft tissues the ulcer will heal with the formation of scar tissue.


Clinical features

1. The floor of the ulcer (part showing loss of tissue, exposing underlying tissues even bone if severe) may be:

(a) Pale and anaemic with watery discharge indolent (static, unhealing) ulcer.
(b) Green or yellow discharge - infected ulcer.
(c) Pink bubbly with red spots - granulating ulcer.

2.The edge of the ulcer (boundary between floor and surrounding skin) may be:

(a) Well defined, straight or undermined red and shiny - ulcer spreading.
(b) Hard, oedematous, overhanging floor - ulcer chronic.
(c) Shallow, sloping out from floor with bluish tinge - ulcer healing.

3. The base of the ulcer (zone of tissue immediately surrounding and underlying the ulcer) may show:

(a) Gross induration (hardening), the extent of which varies according to the severity and duration of the ulcer.
(b) Pigmentation due to breakdown of red blood cells.
(c) Poor circulation.
(d) Coarse skin texture with heavy scaling or papery thin and eczematous tissue.
(e) There may be partial scar tissue.

4. Oedema of base of ulcer and foot and ankle to shoe line.

5. Considerable pain around the ulcer, especially if infected. Pain increased on walking.

6. Limited movement of the foot and ankle.

7. Muscle weakness and atrophy - mainly of calf muscles with loss of pumping action.

8.Walking pattern poor with no push-off.

Treatment

1. Conservative.
2. Surgical.

Conservative

The general aims are to:

l. Relieve pain.
2. Relieve congestion and reduce oedema.
3. Improve general circulation to lower limb.
4. Soften induration of lower leg especially around ankle area.

5. Mobilize joints of lower limb especially foot and ankle, and strengthen lower limb muscles especially calf.
6. Improve condition of skin of lower leg.
7. Teach home care and management.

The local aims are to:

1.Increase circulation to ulcer to promote healing.
2.Clear any infection.
3. Reduce oedema and induration around ulcer.
4. Free adherent ulcer from underlying tissues.

Methods of treatment

Soft-tissue techniques

Remove all bandages and dressings, clean wound and cover with gauze swabs during general techniques.

The leg is elevated to an angle of 45° at the hip to aid venous drainage.

Deep manipulations are given to the whole limb to reduce oedema and congestion, beginning with the thigh and continuing down the limb. Slow, deep kneading (squeezing kneading if necessary) followed by slow, deep strokes of effleurage. Progress to picking up and wringing on the thigh. Special attention should be paid to the dorsum of the foot, the region of the tendo-calcaneus and behind the mallE0li. Thumb kneadings over the anterior tibialis muscles, finger or thumb kneadings over above areas and deep kneading to the foot followed by deep effleurage can be given.

The region of the ulcer is next treated with finger and thumb kneadings to soften the induration, working inwards from the periphery to the edges of the ulcer itself. Care is necessary if the skin is thin when the techniques must be stationary. Support one side at a time if the ulcer is very painful.

The ulcer can also be moved from side to side, the physiotherapist placing her fingers on one side and her thumbs on the other, to free it from the underlying tissues and improve the circulation.

This can be progressed to wringing as the mobility of the tissues improves.

Local techniques are better avoided when the ulcer is infected.

Ultraviolet rays

For infected ulcers

This can be given to destroy micro-organisms and increase circulation to the area. The Kromayer lamp is most commonly used (for very large ulcers the air-cooled mercury vapour lamp). A large dose (fourth degree (E4) or double fourth degree (E4 x 2) is given to the base of the ulcer, the edges being screened with damp, sterile gauze. This is repeated two or three times a week until the ulcer is clear of infection. If the edges are clear of infection a first-degree (El) or suberythema (E0) may be given to the edges and surrounding skin to promote healing. This can be repeated daily.

For healing ulcers

As the ulcer heals it grows inwards from the edges or outwards from islands in the middle. The ultraviolet rays are given to promote granulation tissue. An El (for shallow ulcers) or an E2 (for deep ulcers) is given to the floor of the ulcer and an El or E0 is given to the surrounding skin. The E0 or El is repeated daily and an E2 is given twice weekly.

These dosages can be given with blue uviol or Cellophane filters which cut out the abiotic (UVC) rays and stimulate growth of granulation tissue. With these filters the El of the lamp is considerably more, therefore a test dose with the filter is necessary.

For indolent ulcers

The ultraviolet rays are given to stimulate the circulation. Absorption of the rays produces hyperaemia in the congested area and produces an increased exudate. An E3 is given to the floor with the edges screened and an El or E2 to the edges and surrounding skin. As the ulcer improves the base should become pink and vascular when the E3 can be reduced and treatment given as for a healing ulcer.

This can be given with coupling cream to the surrounding skin or in a sterile saline bath to the ulcer itself as well as the surrounds.

The ultrasound will promote healing of the ulcer, soften the induration and increase the vascularity in the surrounding tissues. The 3 MHz head using a low dosage, e.g. 0.25-0.5 W/cm2 is applied for 5-10 min. A pulsed beam is used if the area covered is small but a continous beam is used if the area is large. The dosage can be increased up to 1.0 W/cm2 for chronic indurated areas in the lower leg. Ultrasound is contraindicated in the presence of superficial or deep venous thrombosis.

Pulsed electromagnetic energy (PEME)

PEME is the production of short bursts of high frequency currents. Continuous high frequency currents at sufficient intensity produce heat in tissues. If PEME is applied to tissues there is a relatively long ’rest’ period and during this time heat is dispersed by the circulation thus producing non-thermal effects. When wounds are treated with FEME there is increased organization of connective tissue and growth of epithelial tissue thus promoting healing. A pulse duration of 65 microseconds (us) set at a frequency of 400 pulses per minute (ppm) given for up to 30 minutes daily would be suitable for treating wounds.

Ionozone therapy

This is the production of steam which is ionized, by being passed over a mercury vapour arc, into a mixture of ionized water, ozone and oxygen. It is applied at approximately 35cm from the ulcer and surrounding area for 10-20min. This will reduce pain, overcome infection and promote healing. The steam is directed horizontally with the patient appropriately positioned. It is useful where the patient cannot be positioned satisfactorily for screening for treatment with ultraviolet rays. All grease should be removed from the ulcer and surrounding areas. If the surrounding skin is thin the area should be screened with a waterproof material or the distance should be increased up to 50cm. The treatment is applied daily to infected ulcers and reduced to two or three times a week as healing occurs.

Light amplification by stimulated emission of radiation (laser)

Beams are in the visible and infra-red part of the electromagnetic spectrum (600-950 nm). Due to their ability to increase vasodilatation, ;he number of fibroblasts and the size of cells at wound margins which divide quicker, laser beams can be used.

The wound should be as dry as possible and oil free. Any oil-based dressings must be cleaned off. A cluster probe with a number of wavelengths is most effective for ulcers. The energy dosage should be U/cm2 which is less than the normal 2-4J/cm2 because there is no skin. This is achieved by applying the probe at 30 mW for 33s. A higher power for a shorter time is more effective.

The probe is held at 90° to the wound just off the surface of the ulcer. In painful ulcers longer pulses are used at a lower frequency and extensive ulcers are treated in sections. Treatment should be given on alternate days.

Pneumatic compression

A double-layered plastic sleeve which may have zip or Velcro fastenings is applied to the lower limb. It can cover dressings and provides intermittent or sequential compression where the ankle, knee and thigh are compressed in turn. This is followed by arest period for approximately 1 minute. Pressure can be varied up to 100mm Hg but is normally between
35 mm Hg and 55 mm Hg. Some machines blow cool air over the leg to make it more comfortable. The sleeves are worn up to 24 hours per day. The veins are compressed for relatively short periods of time which greatly reduces venous stasis, improves venous circulation and promotes healing. Due to the mechanical compression and relaxation there is reduction in oedema.

Support and pressure

Graduated compression which reduces from distal to proximal increases venous blood flow and prevents dilatation of the leg veins. The support enhances the muscle pump and aids reduction of oedema round the ulcer and in the limb generally. A 2cm sorbo pad or gauze compress is applied over the dressing, of a size corresponding to the ulcer and the oedematous area round it.

Wool or felt padding is placed in the grooves behind the mallE0li and round the lower leg and foot. It is kept in position by a gauze bandage. Over this an elastic bandage, Tubigrip or elastic stocking is applied from the metatarsal heads to the tibial tubercle. The elastic bandage starts from the inner border of the foot level with the metatarsal heads and is carried straight round the foot for 1½ turns. It is then taken over the dorsum, round the back of the heel to just above the starting point. Hold the bandage here while continuing outwards and downwards across the dorsum, under the sole and upwards (near the heel) across the front of the ankle. These two turns must be accurately applied in order to give the essential support and pressure round the tendo-calcaneus and mallE0li. The heel must be covered completely, otherwise there will be pain and swelling. Hold the ankle turn so that it is fixed by the first spiral turn. It is then continued as a simple spiral to the tibial tubercle. The tension should be half-full stretch of the bandage. When using Tubigrip, two layers should be used, the inner one extending to the bulk of the calf muscles and the outer to the tibial tubercle. The support can be removed at night when the leg is elevated but is worn throughout the day for at least 3 months after the ulcer is healed. The patient is taught to reapply the pressure bandage a few times a day to maintain tension and vary the pressure areas of the bandage on the skin.

Exercises

Active exercises of the ankle, subtalar and mid tarsal joints are essential to improve venous circulation and mobilize the joints. The exercises should be carried out with the elastic support removed to emphasize joint mobility and against the resistance of the support to increase circulation and muscle strength especially the calf muscles. Reeducation of walking with emphasis on the ’push-off’ must be given. Functional activities which particularly work the ankle should be practised, for example:

1. A treadle machine.

2. Cycling.

3. Foot power loom.

4. Walking a dog.

If the joints of the knee and foot do not regain full range with active exercises, mobilizations (passive oscillatory techniques), both physiological and accessory movements may be applied.

The exercises must be carefully taught and explained to the patient who must practise them frequently throughout the day.

Advice

When sitting, the patient must elevate the legs with support under the knees and avoid standing still for any length of time. Any increase in pain must be reported.

Cleaning and dressing the ulcer

The ulcer is cleaned prior to applying electrical techniques or local massage and is dressed before giving exercises. The cleaning and dressing should be carried out using a ’non-touch’ technique with sterile packs, instruments and lotions. Cotton wool balls soaked in saline (clean ulcer) or hydrogen peroxide or Eusol (infected ulcer) are used for cleaning. If the ulcer is very painful it may be irrigated instead of cleaned with cotton wool. Sterile gauze swabs soaked in saline can be used for screening the ulcer for UVR. A great variety of ointments, solutions and preparations are available for dressing the ulcer and surrounding skin. A desloughing agent may be applied to a very infected ulcer and specific antibiotic creams may be necessary for specific infections. Paraffin gauze is useful to protect the floor of a granulating ulcer. A soothing cream, e.g. calamine, may be used if surrounding skin is irritable, painful and eczematous b’jvarachis oil is better for dry, scaly skin.

A gauze compress covering up to 2 cm of the ulcer surrounds may be used if the ulcer is shallow and granulating at the edges. For deep ulcers Silastic foam (a silicon-based fluid which sets to the shape of the ulcer) may be used during the granulation stage but for infected ulcers ribbon gauze soaked in Varidase packed into the cavity ensures that the lotion is in contact with the floor. Finally the ulcer is dressed in a non-absorbent dressing, e.g. Melolin or Perfron.

If the ulcer has a copious discharge, cotton wool padding will absorb the exudate. A sorbo-rubber pad or white felt 2cm thick can be applied if the ulcer is overgranulating, or there are persistent patches of local oedema (and induration).

An ulcer often responds to one solution or dressing for 1-2 weeks and then slows up. When this happens it is useful to change the solution or dressing.

Prognosis

With good treatment the majority of ulcers will heal but some take many months. Recent ulcers heal quicker than long-standing ones: oedema, obesity, arthritis and lack of nutrition are factors which delay their healing. Ulcers tend to heal quicker with intelligent and cooperative patients. Without adequate care ulcers will break down again.

Complications

1. Superficial venous thrombosis.
2. Deep venous thrombosis.

Records

1. Tracings and graphs

Tracing show changes in the shape but not in depth of an ulcer. A sterile glove (two layers of Cellophane) is placed over the ulcer and a tracing is made on the top layer. The underneath layer (next to the ulcer) is thrown away and the tracing is transferred to graph paper for easy comparison.

The tracing should be taken at the first attendance and at regular intervals thereafter.

2. Photography

Photographs of the ulcer taken at regular intervals give an indication of its state and depth in addition to its area but are more expensive than graphs.

Surgical

The healing of large venous ulcers may be hastened by surgical intervention. This may include:

1. Ligation of veins.

2. Debridement and skin grafting.

Ligation of veins is usually necessary to improve the venous return of the lower limb which is the predisposing cause of the ulcer.

Debridement and grafting - If an ulcer is infected it must be cleaned before applying a skin graft. This may be done by local application of antiseptic lotions or UVR. Various types of split skin grafts may be carried out. Mesh grafts are more successful particularly if the ulcer is large. The skin is normally taken from the thigh and passed through a mesher which makes multiple slits enlarging the graft. The slits enable the circulation to move freely through the graft and therefore ’take’ readily.

9.2.2 Arterial (ischaemic) ulcers

Aetiology

Sex - Men more than women.
Age - Elderly.

Site - More commonly on toes, foot and heel but may be found on lower leg.

Cause - Lack of nutrition to the skin due to inadequate arterial supply.

The floor of the ulcer is pale, anaemic and liable to infection. The surrounding skin may be normal or ischaemic.

Treatment

The ulcer will not heal unless the blood supply is improved and usually surgery is necessary. After surgery local treatment as for a venous ulcer will reduce infection and promote healing.

9.2.3 Pressure sores

Pressure sore is a term used to describe any pressure injury, which may vary from an area of erythema to a deep-seated ulceration exposing the underlying bone.

Aetiology

Age - Can occur at any age but is more commonly found in the elderly (75% found in over-seventies).

Sex - Sexes equally affected.

Site - Found in pressure areas, e.g. heels, buttocks, hips, elbows.

Condition - More commonly affects patients with neurological disorders, e.g. paraplegia and Parkinson’s disease.

Cause

This can be external factors (in the environment) or internal factors (in the body itself).

External factors

Prolonged and constant pressure causing deficiency of blood supply. The tissue damage will depend on the amount and type of pressure - shear or friction. In shear pressure the skin remains stationary and the underlying tissues move forward, destroying the circulation but in friction the skin surface moves over the bed surface causing a superficial abrasion. The pressure may be caused by immobility of the patient due to:

1. Post-operative pain.

2. Immobility in a plaster of Paris.

3. Unconsciousness.

4. Loss of sensation where the patient does not feel pain.

5. Prolonged bed rest.

Internal factors

1. Bony prominences, e.g. sacrum or greater - trochanter, cause pressure to build up internally.

2. Increased muscle tone results in the patient remaining in a fixed position with increased pressure.

3. Illnesses reducing the nutritional state of the body.

4. Incontinence results in skin breakdown due to moisture.

5. Weak or wasted muscle bulk causes poor - protection for the underlying tissues.

6. Diabetes may lead to trophic ulcers.

Pathology

There are two types of pressure sores - superficial and deep.

Superficial type - This begins with breakdown of the skin surface resulting in destruction of the epidermis, dermis and possibly subcutanE0us tissues. The resultant ulcerated area may become infected with a yellow or green exudate.

Deep type - This begins in the subcutanE0us tissues overlying bony prominences. It results in necrosis of the subcutanE0us tissue, fascia and possibly muscle tissue. The only sign may be a slight reddening of the skin surface. In severe cases the destruction may spread superficially through the dermis and epidermis until a deep cavity is exposed.

Superficial pressure sores are three times as common as deep sores but deep sores occur in seriously ill patients and are associated with a very high mortality rate.

In both types the pressure compresses the tissues, occludes the blood supply and the nutrition is cut off. If the pressure is prolonged acute changes of inflammation take place with necrosis of tissue, suppuration, and healing by second intention.

Clinical features

There is an open area of varying size on a pressure site. The floor of the sore may be pink and vascular or filled with infected exudate. The cavity may be shallow or deep with loss of subcutanE0us tissue and exposure of bone. Around the cavity the skin is red or blue.
The patient will complain of pain if sensory nerve endings are not destroyed.

Prevention of pressure sores

Prevention of pressure sores is better than cure.

Aims of prophylactic treatment - To relieve pressure and prevent breakdown of skin.

Medical

1. Burning the patient every 2 hours day and night ’and avoiding pressure on the sore, e.g. for a trochanteric sore change from lying to side lying on the unaffected side.

2. Use of a special mattress or bed designed to relieve pressure:

(a) Water bed which provides even pressure over all parts of the body.

(b) Ripple mattress which continually alters the pressure points.

(c) Net bed - an open mesh net provides reduced pressure and is suspended between two wooden rollers allowing easy turning of the patient.

(d) Air fluidized bed - air is pumped through a sand medium giving complete flotation. The fluidization can be switched off giving a solid surface for ease of handling.

(e) Low-air-loss bed - consists of waterproof ^X sections filled with air to different pressures
providing even pressure distribution.

(f) Sorbo packs which can be positioned to keep •”’ susceptible areas pressure free.

3. Sheepskins can help to keep skin dry and reduce friction but are not suitable for incontinent patients. They can vary in size from a small square to one which protects the whole body. Boots lined with sheepskin help to prevent pressure sores on the feet.

4. ’Roho’ cushion - an air-filled cushion which moulds to any shape and spreads pressure evenly.

5. Encourage patient to be mobile as soon as possible and encourage short walks.

6. The patient is instructed to inspect pressure sites for signs of pressure and taught methods of self pressure relief.

7. Treatment of associated diseases will help to prevent skin breakdown. Incontinence must be treated, oedema reduced and anaemia corrected.

8. A balanced diet to maintain patient’s general health is essential.

9. Good instructions in turning and lifting to the patient, the patient’s relatives and carers is necessary if prophylactic measures are to be completely successful.

10. Dermalex spray.

Physiotherapy

This may include:

1. Exercises for strengthening muscles to enable patient to lift himself/herself in bed or chair for pressure relief.

2. Active exercises to encourage mobility in bed and walking, assisted if necessary, as soon as possible.

3. Ice massage over a reddened area for a few minutes several times a day will increase circulation and reduce oedema, thereby preventing tissue breakdown.

4. Relaxed passive movements to paralysed limbs, aid circulation and prevent contractures which might produce pressure sores,

Management of pressure sores

The aims of treatment are to: relieve pressure, reduce infection, improve circulation and to promote healing.

Medical and surgical

1. Turning and positioning the patient, together with the use of suitable beds and cushions as described in prophylactic treatment.

2. Aseptic cleaning to reduce infection if necessary followed by the application of a dressing to promote healing, e.g. non-stick Perfron, semi permeable Op-Site, Silastic foam for deeper granulating sores. Bactigras for infected sores or paraffin gauze for large granulating sores.

3. A high-protein, high-calorie diet including all vitamins and iron improves the patient’s general health and promotes healing.

4. Surgical excision and grafting. If the sore is infected debridement (excision of infected tissue) is necessary first. When a large sore is healing and unlikely to be subjected to further pressure a skin graft may be sufficient but a rotation flap may be necessary if there is any danger of further breakdown. In a rotation flap there is rotation of muscle and skin flap to cover the defect and an additional skin graft to cover the area left by the flap. Following the flap, pressure must be relieved until the wound begins to heal.

Physiotherapy

The methods of treatment are similar to those advocated for venous ulcers: massage round edges of sore, ultrasound to surrounds, UVR to the floor and edges, Ionozone, ice, PEME and laser. Unlike ulcers oedema of the surrounding tissues and limited joint movement are not features of pressure sores, therefore compression and support bandaging are not used.

Tracings can be used to show decrease in the size but not the depth of a sore.

The response of the sore to the different modalities is very variable and the choice will depend on the state and progress of healing.

The prevention and treatment of pressure sores includes a good team approach by nurses, physiotherapists, doctors, dietitians, carers, relatives and not least the patient who must ensure pressure relief.

9.3 Lymphoedema

This is the collection of lymph in the subcutanE0us tissues due to an abnormality of the lymphatic system.

Types

Primary - There is an inherent abnormality in the lymphatic system.

Secondary - The lymphatics have been damaged causing obstruction of lymph flow.

Aetiology

Primary

Sex - Females more than males.
Age - It can occur at any age. For example:

1. At birth due to lymph vessels being small and few or dilated and tortuous.

2. At puberty due to the lymphatic system being unable to cope with hormonal changes.

3. Later in life due to deterioration of the lymphatic system.

Secondary

This is caused by obstruction of the lymphatic system due to:

1. Malignant disease, e.g. breast cancer in upper limb or pelvic tumour in lower limb.

2. Radiotherapy to pelvic or axillary regions, e.g. after mastectomy.

3. Chronic inflammation leads to fibrosis and occasion of lymph vessels.

4. Filariasis caused by infection through mosquito bites.

Pathology

Owing to obstruction or anatomical abnomalities protein molecules escape into the surrounding tissues. The fluid stagnates and coagulates because of its increased protein content. Fibrosis then occurs with later thickening of the skin. The changes are localized to the subcutanE0us tissues by the deep fascia.

Clinical features

1. Mainly lower limbs affected.

2. Gradual increase in swelling of affected part usually unilateral. Primary lymphoedema begins distally and spreads proximally but secondary lymphoedema may begin proximally.

3. Initially the oedema ‘pits’ on pressure but later it becomes solid.

4. Enlargement of regional lymph glands in secondary lymphoedema.

Management

1. Conservative.
2. Surgical.


Conservative

The majority of patients are treated conservatively.

Apparatus

Machine - This consists of a pneumatic pump with:

1. Pressure control measured in mm Hg or kilopascals. The scale may be deflection of a needle or a knob round a scale.

2. On/off switch.

3. Maybe a time control which varies the ratio of inflation/deflation.

Sleeves - Consisting of a double layer of sealed polyurethane. These can be full upper limb, full lower limb or below knee only. The upper limb cuff is straight but the lower limb has a foot shape at the end. All cuffs taper, the broader end being proximal to allow for the limb being larger at this part. Some have zips or Velcro fastening to make application easier.

Sleeves with more air entry holes give more even pressure.

Pneumatic compression

The compression may be:

1. Intermittent - The whole sleeve is alternately inflated and deflated.

2. Sequential - Sections of the sleeve inflate and deflate in turn giving compression to the limb from distal to proximal.

Application

All clothing and jewellery must be removed to avoid restricting the circulation. The limb should be well supported and elevated during treatment. The sleeve which is applied on top of a layer of Tubigauze (thin cotton gauze) must include all the hand and foot otherwise the circulation is restricted and the patient complains of pins and needles.

Assessment

Before beginning treatment the joint range and muscle strength of the limb should be recorded. Palpation of the oedema should be made and the mobility of the tissues noted. Limb measurements must be made at the set levels and ideally repeated by the same person. These measurements are taken in:

1. The upper limb at:
(a) Axilla.
(b) 8cm proximal to olecranon.
(c) 11 cm distal to olecranon.
(d) Wrist.
(e) Level with web of thumb.

2. The lower limb at:

(a) Groin.
(b) 15cm above base of patella.
(c) 15 cm below apex of patella.
(d) Ankle (mallE0li).
(e) Middle of metatarsals.

Both the affected and unaffected limbs must be measured for comparisons immediately after treatment, 1 hour later and in the evening.

Treatment

The pressures for the upper limbs and lower limbs are the same. The pressure cycles may be:

1. Fixed - 30-45 s inflation 15s deflation.

2. Variable - inflation time can be increased up to
60s.

The machine should provide the same physiological conditions as a normal muscle contraction. for 30min and assess later. Repeat treament

Suitable outline plan

Begin with 40mm Hg for 30min and assess immediately and 1 hour later. Repeat treament twice daily.

Pressure is kept the same and time is gradually increased until at the end of a week the dosage is 40mm Hg for 1 hour.

In the second week increase the pressure by 5 mm Hg per day until 65mm Hg (maximum) is reached. Treat for 1 hour twice daily. If patient complains of pain use a lower pressure and treat more frequently,

e.g. 45 mm Hg three times per day or 30mm Hg four times per day.

Treatment should be carried out 7 days per week.

Variations

If the patients’ condition allows treatment can begin with 40 mm Hg for up to 2 hours and repeated up to three times daily. The pressure can be increased during the first week.

Treatment can be given as an inpatient, outpatient, by the community physiotherapist, or machines may be loaned for home treatment usually for a month and then reassessed.

Soft-tissue manipulation

Before applying pneumatic compression give massage round each shoulder region because the sleeve does not extend to the shoulder region and it helps to promote circulation proximally. Begin with deep kneading or squeezing, kneading if the tissues are stretched followed by clearing effleurage to the axilla. As the tissues become more mobile picking up and wringing are used in addition to kneading. Finger or thumb kneading is used for localized thickenings.



Exercises

The aim of the exercises is to aid removal of tissue fluid from the subcutanE0us tissues. The exercises are performed slowly but firmly with the limb in elevation. This can be achieved by the limb resting on three or four pillows with the distal joints higher than the proximal joints.

The exercises should be done three times a day and each one repeated 15-20 times. For example, for upper limb:

1. Fingers bend and stretch.
2. Wrists bending forwards, backwards and circling.
3. Elbow bend (fingers to shoulder) and stretch.
4. Sitting; arms place behind neck and behind waist.

Support

Lymphoedema sleeves or stockings should be worn 24 hours a day because the effects of treatment last longer. They come in different sizes and extend from the bases of the fingers and toes to the shoulder and groin respectively.

The support should be removed for treatment with the compression machine. If sleeves or stockings are not available an elastic bandage can be applied with the pressure gradually decreasing from distal to proximal. Poor bandaging aggravates rather than improves the condition.

Advice to patient

1. Use the limb as normally as possible.

2. Avoid minor injuries such as scratches which provide an entry for infection. Should they occur treat with an antiseptic. If the area becomes red, swollen or hot seek medical advice as soon as possible.

3. Avoid injections on the affected side.

4. Do not take hot baths since the limb will swell further - cool baths are allowable.

5. Do not wear tight bands (garters) or jewellery (rings) on the swollen limb.

6. Elevate the limb by putting the lower limb on a chair during the day and raising the foot of the bed at night. Support the upper limb in a sling or sit for short periods with the hand on the head.

7. Do not carry heavy shopping or cases with an affected upper limb.

8. Wear footwear that supports the foot.

9. Wear a thimble when sewing.

Surgery

A minority of patients require surgical treatment for gross swelling of the limb and recurrent episodes of infection. Some surgeons remove excess tissue while others is addition attempt to create communication between superficial and deep lymphatics. Preoperative treatment is similar to conservative treatment and post-operative treatment aims to improve lymph flow and function of the affected limb. The limb is supported in elevation and active movements to stimulate the circulation are encouraged. In the lower limb the patient is ambulant as soon as possible and is given gait re-education to improve function. Ultrasound or pulsed electromagnetic energy may be used to mobilize the tissues.

9.4 Scar tissue

Scar tissue gives rise to:

1. Pain which can be caused by:

(a) Nerve tissue becoming involved in the scar.

(b) Venous congestion in deep scars.

(c) Traction on the neighbouring structures when the scar is adherent.

2. Limitation of movement which arises when the scar is over a joint line.

3. Impaired blood supply when the scar constricts blood vessels.

Common sites of scars requiring treatment

1. Palm of hand following release of Dupuytren’s contracture.
2. Knee and elbow after surgery
3. Ankle after an internally fixed fracture.
4. Hip surgery.
5. Burns and skin grafts.

Treatment

This varies according to the age of the scar.

Recently healed scars (up to 3 weeks)

The aims are to:

1. Prevent contractures and loss of joint movement.
2. Mobilize the scar.

Massage

This may include stroking round and towards the scar with the thumb. Thumb kneading on one side of the scar while the other side is supported avoiding stretching which could split the fibrin.

Wax baths - improves the condition of the skin and makes it more supple.

Active exercise to move the joints through full range without stretching the scar transversely.

Adherent scar (over 3 weeks)

The aims are to:

1. Mobilize the scar.
2. Stretch adhesions and contractures.
3. Regain normal function.

Massage

Stroking and thumb kneading can be applied deeply and vigorously. Modified picking up and wringing between thumb and index finger and skin rolling are useful for mobilizing the scar. If the tissue is tough and thick transverse frictions may be applied to the scar.

Ultrasound

Applied over the scar this increases tissue length and the mechanical movement of tissues makes the scar tissue more pliable. It also mobilizes the scar from the underlying tissues. The frequency should be 3 MHz. An intensity of 1W/cm2 for 4 minutes increasing up to 10 minutes has been found to be effective. Pulsed mode is suitable for small scars, continuous for large scars.

Passive stretching

Once the scar tissue has been mobilized and lengthened with massage and ultrasound passive
stretching may be applied if the scar is near a joint. A slow continuous stretch may be used or an oscillatory technique may be applied or (often) a combination of both is effective. Active exercise should follow passive stretching and the patient should continue with this at home.

Other modalities

Serial splinting for a contracted scar. Whirlpool baths which soften scar tissue may be applied by immersing the affected part in a hot bath through which an air stream is passed to agitate the water molecules.