Applying a bandage is an art form. Too much padding? It won’t immobilize the limb efficiently. Photo by Dr. Phil Zeltzman Open wounds from a tight bandage in a 6-year-old Setter’s hind leg. Not enough padding? Be prepared for pressure sores. Too tight? We are not discussing tourniquets here! Too loose? Be ready for an unhappy client when the bandage falls off. Placing a bandage is also a whole science.1 It’s much more complicated than it looks. And like everything else in life, there is a right way and a wrong way to place a bandage. A modified Robert-Jones, arguably the most common bandage, is made of three layers, unless, of course, you count your technicians’ creative decorations as a separate layer. Stay in Contact The first step in bandaging a limb is the placement of tape stirrups. As long as the health of the skin and the location of the open wound allow, strips of tape are placed laterally, medially or cranially to the leg. It is better to avoid placing a stirrup caudally, as it could damage the foot pads. The tape will be stuck later onto the bandaging material to prevent it from slipping. The contact, or primary, layer is in contact with the skin or the wound. The dressing used depends on the nature of the problem treated: plated fracture stabilized postoperatively with a splint vs. open wound management vs. the site of a skin graft. Each patient, each wound, each indication has its ideal dressing: adherent, non-adherent, occlusive, semi-occlusive, etc. The human and veterinary markets offer a plethora of dressings. They include alginate, hypertonic saline, hydrocolloid, hydrogel, antimicrobial, bioactive, silicone, cellulose and many more. Some manufacturers provide decision trees, which help choose the appropriate dressing based on the nature of the wound and the healing process. In the Middle The intermediate, or secondary, layer of a bandage holds the contact layer in place and is designed to absorb exudate, blood, bacteria, debris and proteolytic enzymes and keep them away from the wound. The idea is to wick fluid from the wound and the primary layer without soiling the outer layer. This absorbent layer should therefore be made of a thick layer of cotton or cast padding. Extra care is used to protect bony prominences, such as the carpus, the point of the elbow, the hock and the calcaneus. Adding more padding in these areas may increase pressure, so a “doughnut” may be used. The ring, most often made of gauze, encircles the problematic area. As the bandage applies pressure on the at-risk area, the pressure is distributed around the bony prominence. On the Outside Photo by Dr. Phil Zeltzman Open wounds from a tight bandage in a 6-year-old Setter’s hind leg. The outer, or tertiary, layer holds the two previous layers in place and protects them from the outside world. A common material used for this layer is a cohesive bandage, which sticks to itself. If exudates “strike-through,” then the bandage should be changed as soon as possible because bacteria from the environment could travel into the bandage and cause an infection. In a highly exudative wound, strike-through is a helpful criteria to determine how frequently the bandage should be changed. In the limb, the different bandage layers are applied from the toes to the proximal part. The very distal extremity of digits 3 and 4 are left exposed to monitor swelling. Padding is overlapped by 50 percent to help conform the bandage to the leg. Folds are avoided because they can cause pressure sores. An Elizabethan collar or similar device is used to prevent self-trauma or destruction of the bandage. Once the application of a modified Robert-Jones bandage is mastered, it can be modified using a plastic or Spica splint, a metal rod, a cast, etc. Top 10 Goals Photo by Dr. Phil Zeltzman Photo by Dr. Phil Zeltzman A bandage can serve many purposes. Let’s review the goals: Protection from the outside world: Applied before definitive surgery, a bandage can prevent desiccation of an open wound. Keeping the wound moist is encouraged because it promotes the body’s natural healing capabilities. . Protection from the patient: Bandages can be used to some degree to prevent self-mutilation. They also can prevent licking and chewing a Penrose drain. . Antisepsis: Because it acts as a barrier, the bandage reduces contamination of an open wound. Some suggest soaking gauze in a diluted antiseptic solution (chlorhexidine or povidone-iodine), but this is a controversial subject. Most would rather use isotonic lactated Ringer’s solution if a wet-to-dry bandage is indicated. . Immobilization: A splint can reinforce the surgical repair of a fracture, a luxation or a tendon injury. . Debridement: One of the roles of a wet-to-dry bandage is to debride an open wound when the bandage is removed. Using fluids to rehydrate the dry dressing—to “be nice” and avoid hurting the patient—defeats the purpose. Necrotic tissues should be removed. Therefore, sedation or anesthesia, as well as pain management, are required. . Absorption: Blood, exudate, debris, bacteria and proteolytic enzymes can be absorbed into the second layer of the bandage. . Pressure: Though no substitute for a good surgical technique, a bandage may help reduce edema and dead space and decrease the risk of hematoma or seroma. Similarly, a bandage may help to reduce hemorrhage. Without question, this is risky territory because excessive pressure can lead to disaster, including ischemic necrosis, pressure sores, loss of a digit or even loss of a limb. . Pain relief: By limiting motion, a bandage can be part of pain management. This is true preoperatively when a splint or a spica is applied to stabilize a fracture. It also is true post-operatively, after fracture repair. . Acidification: Chemistry fans will be happy to know that a bandage creates an acidic environment by decreasing the loss of CO2 and absorbing ammonia secreted by bacteria present on a wound. The acidification, in turn, reduces the number of bacteria in the wound. . Information: The amount, color and nature of the drainage observed when the bandage is changed provide information that can help determine whether anything should be changed. A greenish exudate, for example, may indicate that the wound was contaminated by Pseudomonas. Detailed care information should be given to the client in writing to limit complications. For example, clients should be shown how to assess swelling by checking digits 3 and 4. They should be told to cover the bandage when the pet is outside and to uncover it while indoors. Following these simple guidelines will ensure that bandages play their main role: to help speed up healing. <HOME> Dr. Phil Zeltzman is a board-certified surgeon with a mobile practice in Allentown, Pa. His website is DrPhilZeltzman.com. This article first appeared in the July 2010 issue of Veterinary Practice News. Click here to become a subscriber. They Used to Apply What on Wounds? REFERENCE 1. Various sources, including M.M. Pavletic, “Wound care products and their use,” Atlas of Small Animal Wound Management and Reconstructive Surgery, 3rd edition. Wiley-Blackwell, 2010.
