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PROFESSOR  W. G. FEGAN

This article is written with special reference to the injection treatment of varicose veins.

In compression sclerotherapy the important factors are the exact diagnosis of the incompetent perforating veins and the intravascular injection of a sclerosant, sodium tetradecyl sulphate, at these sites. Digital isolation of the segment of the vein to be injected is desirable, as is injection into an empty vein by elevating the leg. However, it is often not appreciated that correct bandaging is the most important part of the technique and a high failure rate in using this treatment can be accounted for by incorrect application of bandages in many cases. If the compression is inadequate or the bandage falls off, widespread thrombophlebitis will occur, followed by recanalization of the vein, and the leg may be left in a worse state than before treatment.

The art of bandaging appears to be so simple that it would seem that any person could undertake it. However, when it is appreciated that a bandage applied by one doctor will stay in place for 6 weeks, while that applied by another can fall off as the patient walks out of the hospital door, although they appear similarly applied, one realizes that there is more to bandaging than is apparent on first assessment. The object of bandaging is functional. A bandage is put on, not to obliterate the limb from view, but to build up a uniform tension throughout the limb.

The bandages, when applied, should effect a mean compression which is sufficient to obliterate the superficial veins, but which should not interfere with the arterial blood supply of the limb and the venous return in the deep veins. In judging efficient bandaging it is more important that the bandage should feel comfortable rather than appear as a neat pattern. The appearance of the bandage is much less important than the sensation of support that it gives to the patient.

Bandaging is a tactile proprioceptive art. In order to bandage a limb it should be fixed between the bandager's body and the couch. When endeavouring to pass on to my colleagues the art of bandaging, I usually suggest that they should close their eyes and allow themselves to be guided by proprioception and touch. Joint sense and touch are normally distracted by visual impulses. Both hands are used in bandaging, but each has a different purpose. The left hand, by touch, should direct the activities of the right hand. It is a bimanual activity which relies on one's sense of touch and joint sense.

The left hand, as it palpates the surface of the limb, assesses and relays an estimate of the amount of tension that is being produced by each turn of the bandage. The information transmitted from the left hand guides the right hand as to the direction and tension of the pull with which the bandage should be applied. The tactile information of the left hand which moulds the bandage to the limb, and the proprioceptive impulses from the right arm which holds the bandage, will guide the bandage in such a way that it will build up a uniform compression beneath the bandage. Bandaging repeatedly with one's eyes closed helps to develop the tactile and proprioceptive senses required and should result in a higher standard of bandaging. After a short time this becomes automatic and does not require conscious effort.

It does not matter where on the limb one commences bandaging, but unless there is a special reason it is logical to start at the foot. The pattern of the bandage is dictated absolutely by the contour of the limb. Therefore, as each limb has a different contour, each bandage, of necessity, must produce a different pattern. A cotton crepe bandage is used because it is the most comfortable and absorbent. It moulds satisfactorily to the contour of the limb and does not build up pressure during the inactivity of sleep.

To achieve its object a bandage must remain in position for 6 weeks without being either too tight or becoming disturbed, and should allow the limb to move freely. The calf should be bandaged as a spindle. The thigh should be bandaged as a cone using the foldover technique and the fat thigh must have the upper limit of the bandage anchored with adhesive tape, provided the patient is not sensitive to it.

At specifically chosen sites, increased differential compression can be induced by the use of bevelled sponge rubber pads, thus reducing the danger of over compressing the entire limb and interfering with the arterial perfusion. Where the muscle bulk in the limb is maximal, compression should be reduced to the minimum optimal. Rubber pads are incorporated into the bandages at the sites where extra localized compression is required, that is over the injection sites. Rubber pads are of particular help in the angular limb and at the back of the knee where rolling of the bandage is common and may cause chaffing. An unusually prominent malleolus or head of the fifth metatarsal should have a bevelled rubber ellipse placed around or behind it. On the thigh a bevelled rubber pad should be bandaged into position over the course of the long saphenous vein to prevent traumatising the vein by the sharp edge of the bandage.

Bandaging should be continued until the limb gives the impression to the bandager, of uniform tension throughout. The bandager should no longer be able to discern between fat, bone, muscle, thrombosed and unthrombosed veins, and fascial orifices which, prior to bandaging, were easily differentiated when the limb was elevated in the recumbent patient.

Ascending thrombophlebitis can occur in the uncompressed portion of the leg in cases where the bandage rolls down and traumatises the vein. This can be prevented by anchoring the upper turns of the bandage with adhesive tape; by gradual transition of compressed to uncompressed vein by the rubber pad; and by preventing the bandage from rolling down at night by wearing an elastic or nylon stocking which extends above the level of the bandage.

When the patient is examined at the next visit after 2-3 weeks, the bandage should be as perfect as the day it was first applied. In those patients where there is considerable oedema at the time of treatment, periodic rebandaging is essential, and here the application of the heavy elastic bandage, as distinct from the cotton crepe bandage is helpful. It must be removed before going to bed at night and reapplied in the morning, otherwise the patient may suffer cramps. It is important to stress that the elastic bandage is extremely dangerous as each turn is cumulative and that it should not be applied with three turns in the one place, but in a trellis fashion. The elastic bandage should not be applied where there is the least suggestion of arterial inadequacy. The design of application should allow for freedom of walking.

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