Clinical PRACTICE DEVELOPMENT Clinical PRACTICE DEVELOPMENT Using compression therapy in complex situations

Patients presenting with ulceration will often have other chronic illnesses such as diabetes mellitus and osteoarthritis. Compression therapy remains the mainstay of treatment for the majority of these patients, although in some it will be contraindicated. This article stresses the importance of assessment of ulcer aetiology and will discuss the treatment of patients with ulceration who have complex health needs, including those with diabetes, rheumatoid , haematological problems such as sickle cell anaemia, cardiac problems, and wounds caused by trauma.

Christine Moffatt

KEY WORDS Patients with diabetes Many textbooks state that Table 1 Compression therapy compression therapy should not be Factors affecting wound healing Ulceration used in patients with diabetes. This Diabetes is because of the risk of concurrent Rheumatoid arthritis peripheral arterial occlusive disease 8 Peripheral arterial occlusive disease that leads to reduced perfusion and low oxygen levels Sickle cell anaemia and the concern that sensory neuropathy will prevent a patient from that result in tissue breakdown and Pre-tibial crest injuries detecting whether the compression is (Kite and Powell, 2007) causing trauma. However, patients with 8 Smoking is a major risk factor for peripheral diabetes are just as likely to suffer vascular disease (PVD) (Burns et al, 2003). In here is increasing evidence that from a as those without. addition to its role in accelerating arterial the proportion of patients with disease, it is also a potent vasoconstrictor, complex ulceration is increasing Such patients with venous further reducing local tissue oxygen perfusion T 8 (Moffatt et al, 2004). There may ulceration require compression Poor immune function, placing the patient be many reasons for this, the most therapy and, providing their condition at risk of overwhelming infection (Kite and important factor being the increase in is stable, they may heal uneventfully. Powell, 2007). peripheral arterial occlusive disease in Others may take longer to heal, 8 Reduced neutrophil activity increases the the very elderly (Morison et al, 2007). although the exact reason for risk of opportunistic bacteria causing severe As age increases, so does the chance the delay may not be obvious infection (Edmonds, 2007). of having other chronic illnesses such (Marston, 2007). 8 Increased risk of infection with a blood as diabetes mellitus and osteoarthritis. glucose of > 7 mmol/l (International Working Identification of the ulcer aetiology There are a number of factors Group on the Diabetic , 2003). remains a key priority of assessment. thought to affect wound healing in the 8 Patients with two or more factors The true role that other health patient with diabetes (Table 1), who complicating the ulcer aetiology issues play in ulcer healing is often frequently present with other medical (International Working Group on the difficult to determine. Nevertheless, conditions or complications Diabetic Foot, 2003) compression therapy remains the of diabetes. 8 Reduced serum albumin levels of < 30 gm/dl mainstay of treatment for the majority due to infection, starvation, renal failure or of these patients despite their complex Assessment issues acute stress (International Working Group on healthcare needs and healing can be To use compression safely and the Diabetic Foot, 2003) achieved, although more slowly, in effectively, a number of issues 8 Other diabetic complications, such as many cases. must be addressed within a retinopathy and nephropathy, are important comprehensive, structured assessment. indicators that delayed wound healing may If there is any doubt, the patient occur (International Working Group on the Christine Moffatt is Honorary Professor in Nursing and Diabetic Foot, 1999). Health Care, Glasgow University and Co-Director of the should be referred for a specialist Centre for Research and Implementation of Clinical opinion before treatment with Practice (CRICP), London compression commences.

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vessels rarely occurs, therefore, it gives a more accurate assessment of the arterial status 8 If the arterial status of the patient cannot be determined, specialist referral for further vascular assessment should be made.

Assessment of peripheral neuropathy Neuropathy occurs in the majority of patients with diabetes (Edmonds, 2007). This places the patient at risk of Figure 1. The at-risk diabetic foot, with hallux formation and foot ulceration due to valgus, crowded and callus formation over the changed biomechanics of the foot the metatarsal heads. that cause areas of high pressure and friction (Figure 1). Regular assessment of neuropathy using a 10 g monofilament should be undertaken in all patients with diabetes. In addition, it is important to pay particular attention to: 8 Areas at risk of pressure damage from compression 8 Areas of callus formation or previous foot ulceration 8 Foot deformities, eg. hammer toes, Figure 3. Deep pressure necrosis. hallux valgus, Charcot deformity, prominent metatarsal heads, dropped arch 8 Toes, interdigital infection, emboli (Figure 2) 8 Joint function 8 Quality of the skin and signs of trauma 8 Nails, deformities and infection 8 Footwear.

Figure 2. Arterial emboli. Removal of callus Figure 4. Heel . Callus formation can be rapid, The following key priorities relate particularly in patients suffering from to the safe use of compression in hyperglycaemia. Common areas of patients with diabetes. callus formation are over the plantar surface of the foot, particularly where Exclusion of peripheral arterial occlusive disease there are exposed metatarsal heads. A patient’s arterial status should be Compression bandaging traditionally assessed using a clinical history and extends to the base of the toes. Doppler ultrasound. Recording a This will mean that the compression resting pressure index in a patient with is applied over this area acting as a diabetes can be difficult, due to: secondary source of pressure and 8 Calcification of the arteries which friction. The callus area may need to prevents the artery from being remain exposed to avoid this risk and occluded. As a result, a false, to allow for the regular removal of very high systolic pressure is callus by the diabetic podiatrist. recorded which does not give an accurate picture of the patient’s Identification of sub-keratotic haematoma arterial status If the patient has neuropathic foot 8 pressure may be useful in this ulceration or evidence of haemorrhage group as calcification of the toe Figure 5. Crowding of toes. below the callus, compression should

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not be applied without specialist advice. These patients require an urgent specialist referral to the diabetic team and debridement by the diabetic podiatrist

Foot deformities and pressure damage Foot deformities, such as claw toes, hammer toes, prominent hallux valgus (bunions) and bunionettes are all areas at risk of compression damage. Other neuropathic changes include loss of the small intrinsic muscles and subcutaneous tissue in the forefoot area. High compression can result Figure 6. Charcot foot deformity. in deep pressure necrosis over the dorsum of the foot (Figure 3). The Footwear extensor tendon may be prominent, It is vital to assess the patient’s requiring extra protection. footwear. Patients with neuropathy are frequently found to be wearing shoes The area of the heel is rarely that are too tight and the feet should described as an area that is associated be checked for signs of pressure with compression damage. However, damage (Edmonds, 2007). When compression may exacerbate the risk compression is being considered, it of heel pressure ulceration in immobile is important to assess how this will patients who keep their limb in the influence their regular footwear. same position for long periods of time (Figure 4). The loss of sensation Previous history of foot ulceration prevents these patients from being Specialist advice should be sought alerted to the need to change position. before applying compression to patients with a previous history of While compression bandaging foot ulceration or those wearing should not extend over the toes, custom-made shoes. It is vital that care must be taken to ensure that the compression does not become compression will not exacerbate toe wrinkled when the foot is placed deformities or cause tissue damage. in the shoe, as the patient with Crowding and overlapping of toes neuropathy will be unable to tell if Figure 7. Vasculitic ulceration associated with are common problems leading to damage is occurring. rheumatoid arthritis. interdigital pressure ulceration with increased risk of infection (Figure 5). Contraindications to compression therapy Patients with a reduced ankle to brachial pressure There are a number of clinical index (ABPI) Reduced mobility situations when compression should Although reduced compression is Many factors influence the mobility not be used in a patient with diabetes recommended for patients without of these patients. Reduced ankle except under specialist supervision. diabetes with a reduced ABPI of 0.6– movement is a common problem. 0.8, compression should be avoided There are a number of reasons why Concurrent neuropathic foot ulceration in patients with diabetes with an ABPI this may occur. Long-term venous Venous ulceration may occur in a below 0.8 until specialist opinion has ulceration is associated with a patient with concurrent neuropathic been sought. Marshall (2004) outlines progressive loss of ankle function, foot ulceration. In addition to the risks a recommended protocol to assist particularly when compression is being associated with reduced sensation, practitioners when undertaking used. Patients who have a completely compression should not be applied an ABPI. fixed ankle joint are at particular risk over the ulcerated area, as this may of delayed healing due to poor venous act as an additional pressure source How to choose the correct compression return. Patients with diabetes also and can prevent regular inspection of Elastic or inelastic, multi-layer high develop reduced ankle function due to the foot. In a similar manner, a Charcot compression bandaging is the the glycosylation in the subcutaneous deformity with ulceration should not treatment of choice. In young patients tissues causing stiffness and reduced be treated with compression therapy who wish to self-care, compression function (Edmonds, 2007). (Figure 6). hosiery may be a useful option.

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Table 2 Different compression regimes for patients with diabetes

Self-care regimens, using bandages and compression garments, to be considered for patients: 8 With good eyesight who are able to undertake dressings and observe their wound for signs of progress or deterioration 8 Wishing to self-manage 8 With an adequate hyperglycaemic control 8 With a clear understanding of their condition and its treatment 8 With no neuropathy 8 With no history of neuropathic foot ulceration 8 With the ability to concord with professionally prescribed treatment.

Elastic multi-layer high compression bandaging (higher resting pressure), suitable for patients who: 8 Are young and fit 8 Have a normal ankle to brachial pressure index with triphasic waveforms 8 Have no history of cardiovascular disease Figure 8. Patient with rheumatoid arthritis and 8 Have no previous treatment for peripheral arterial occlusive disease ulceration from compression damage. 8 Have minimal or no peripheral neuropathy 8 Have varying levels of mobility, including poor mobility and those who are chairbound 8 Have control of oedema, particularly in the immobile patient.

Inelastic multi-layer high compression bandaging (lower resting pressure), suitable for patients with: 8 Ankle to brachial pressure index > 0.8 with biphasic or triphasic waveforms 8 Good mobility (to assist the action of the bandage during walking) 8 Concerns over distal perfusion at night when wearing bandaging with the foot elevated 8 Severe pain which prevents the use of high pressure elastic bandaging.

Figure 9. Ulceration due to sickle cell disease.

When choosing a regimen for a enough to safely accommodate arthritis are substantially more at patient with diabetes, the factors in compression risk of developing leg ulceration, and Table 2 may help decision-making. 8 If patient is wearing or requires an estimated 5–10% will experience custom-made shoes because ulceration at some point in their lives Application issues of foot ulceration or previous (Cawley, 1987; Pun et al, 1990). About It is important to consider the ulceration, a specialist referral 18% of these ulcers are vasculitic principles of safe application of should be made (Pun et al, 1990) (Figure 7). Poor ankle compression and reduction of pressure 8 In rare cases, compression can mobility causing loss of calf muscle damage. In addition, the following be applied from ankle to knee in pump and ‘pseudo-venous disease’ is points should be considered: patients who wear custom-made another major factor (Cawley 1987; 8 The use of foam dressings or shoes due to foot deformities. This Moffatt et al, 2004). The general health podiatric felt to redistribute type of footwear prevents oedema status of many of these patients is pressure away from vulnerable formation in the foot. This type of poor. Poor nutrition due to loss of areas problem should only be managed appetite, functional difficulties, fatigue, 8 Applying small, soft foam shapes under specialist supervision. stress and anxiety are common between the toes to prevent (Ryan, 1995). interdigital ulceration Patients with rheumatoid arthritis 8 Reshaping the limb to protect Rheumatoid arthritis is a chronic, Recognising rheumatoid ulceration prominent extensor tendons progressive inflammatory tissue These ulcers are often associated 8 Changing to a bandage or bandage disorder of unknown origin causing with high levels of rheumatoid factor system with a lower sub-bandage joint stiffness, ankylosis (fixation of a and severe arthritis. However, they resting pressure joint), and associated joint deformity. In may also be seen in those with stable 8 Reducing pressure over vulnerable addition, the auto-immune component rheumatoid arthritis. The ulcers tend areas by changing the technique of of the disease can affect other systems to have a scalloped, undulating border. bandage application including the skin (Oliver and Mooney, It is not uncommon for rheumatoid 8 Ensuring that the shoes are large 2002). People with rheumatoid ulcers to have a component of

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ischaemic or venous insufficiency, poor healing, even if it is not the Management requires a co- which often makes the condition primary cause of the ulcer ordinated approach with the more difficult to diagnose. Rheumatoid 8 If there is poor ankle mobility, haematology team playing ulcers are generally considered to be venous hypertension is likely to an important advisory role multifactorial in aetiology. be impeding healing. Leg elevation (Olujohungbe and Anionwu, 2007). and ankle exercises will need to Blood transfusions (simple ‘top up’ Medical management be taught and encouraged, as or exchange) have been successfully It is important to recognise that this tolerated used in an uncontrolled manner to is a type of leg ulcer caused by a 8 If vasculitis is suspected, refer for treat sickle cell leg ulcers. The healing systemic disease process. The initial an urgent specialist opinion before effect may be directly due to relief priority in these circumstances is to starting compression of tissue anoxia of the corrected ensure that the appropriate systemic 8 Liaising with the patient’s haemoglobin but also by limiting therapy is used, in addition to local rheumatologist ensures a ischaemia arising from repeated treatment of the wound and the coordinated approach to care vaso-occlusion (Chernoff et al, 1954; use of appropriate levels of 8 Monitoring and controlling wound Serjeant, 2001). compression. Medical treatment of infection. The drugs used for this condition is difficult. Many patients rheumatoid arthritis may also Pain may be severe, excruciating are already receiving high doses of reduce immunity so that fungal and neuropathic in origin. Simple corticosteroid therapy and other infections such as tinea pedis analgesia is inadequate and opioid immunosuppressive drugs. Delayed and ringworm may develop and analgesia and neuroleptic drugs wound healing and susceptibility to place the patient at risk of severe may be required. Referral to a pain infection are common problems. bacterial infection. Osteomyelitis specialist is frequently necessary. is a common complication and is Additional management issues Using compression therapy particularly found in the toes. include: Compression therapy may be of 8 Wound debridement — adequate some value with rheumatoid arthritis Haematological problems, such as sickle pain relief during and after the because of the associated venous cell ulceration procedure is essential insufficiency. However, it may cause Up to 70% of people with sickle cell 8 Compression therapy excruciating pain in a small percentage anaemia are likely to develop a leg 8 Overnight high leg elevation of patients and in these cases should ulcer (Serjeant, 2001). Ulceration — this may drastically improve not be used until the condition has often begins in the mid- to late- the chances of healing stabilised and the pain reduced. It teens and is most frequent in males 8 Preventing wound infections is often difficult to predict which of Caribbean origin. The exact 8 Systemic antibiotics — these patients will experience pain and it is mechanisms are not fully understood, should be reserved for acute essential to ensure that vasculitis has but it is thought to involve a infection with cellulitis. Treatment been excluded, as compression will combination of chronic anaemia, may need to continue for a not only cause excruciating pain but venous hypertension, trauma and number of weeks due to poor may cause rapid tissue necrosis due to localised microcirculatory damage, tissue perfusion. Consultation the already damaged microcirculation due to the affected cells clumping in with a microbiologist is helpful if (Figure 8). the small vessels. Factors to consider recurrent infections occur when managing these patients 8 Skin grafts — these may be Compression should always be include: very effective at reducing introduced slowly (a low pressure of 8 Sickle cell ulcers tend to be slow pain, although the recurrence less than 25 mmHg) and tailored to to heal and recurrence is common rate is high. Following grafting, the patient’s tolerance and pain level. 8 Ulceration occurs most frequently compression therapy must be The level of pressure can be increased in those with sickle cell disease, but used as soon as the patient is if well tolerated. The risk of tissue can also occur in those with sickle mobile to prevent graft rejection trauma from poor bandaging is high cell trait 8 Avoidance of standing for and limb deformities require additional 8 Ulceration is rare in those with prolonged periods of time padding for protection. Beta thalassaemia 8 Psychological support — this 8 Ulcers have a similar appearance is essential as many of these Great care should be taken to to atrophe blanche patients are young and are ensure correct application of the 8 They occur around the malleoli struggling with careers and the bandage. A number of other factors and tend to be painful and sloughy financial implications of this should be considered when managing and are frequently misdiagnosed as disabling condition. these patients, namely: a venous ulcer (Figure 9). Many patients with sickle cell 8 The presence of rheumatoid There is as yet no evidence-based ulceration tolerate multi-layer arthritis will be contributing to treatment for sickle cell ulceration. compression regimens.

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Patients with cardiac failure 8 Large blisters may develop that and Margolis, 2007). A number There is considerable debate may eventually lead to ulceration of wounds that are initially considered concerning the use of compression 8 Oedema may extend to the thighs traumatic may ulcerate, one of therapy in patients with heart failure. and eventually to the genitalia and the most frequent being the This is because compression reduces sacral area pre-tibial laceration. the local blood volume of the legs 8 Increased shortness of breath on by redistributing blood towards exertion, during exercise or when Pre-tibial crest injuries the central parts of the circulation lying down Pre-tibial crest injuries are common in (Mostbeck et al, 1977). This can 8 The jugular vein may be distended the elderly due to falls and knocks to seriously affect cardiac function by 8 Patients may feel generally unwell the leg. They are frequently treated in increasing the preload to the heart 8 Generalised tiredness accident and emergency units where and influencing cardiac output by 5%. 8 Other cardiac symptoms may the flap of tissue is either glued or This can precipitate cardiac failure in include atrial fibrillation secured back in position using 3M™ those at risk and worsen the situation 8 Previous associated cardiovascular Steri-Strip™ Skin Closures. If the skin in those with established heart disease such as myocardial is damaged, the flap may be removed failure. Although rare, death has been infarction. and a dressing applied. reported from the introduction of compression therapy in patients with Using compression therapy In patients who are fit and young decompensated heart failure. When the cardiac failure has been with no factors influencing healing, the assessed and treated it is possible wound can heal uneventfully. However, Recognising oedema due to heart failure and to slowly introduce compression in the elderly, the wound often fails to combination oedemas therapy. The following issues should be heal and a haematoma may develop It is important to differentiate oedema considered: beneath the flap. Infection is an caused by cardiac failure from other 8 Apply reduced compression of less important complication of haematoma forms of oedema. If heart failure than 25 mmHg initially due to the breakdown products that is suspected, a medical assessment 8 In severe cases of heart failure, accumulate in the wound and the should be performed and appropriate begin by applying compression presence of bacteria. The area may drug therapy with diuretics to one leg rapidly deteriorate into an ulcer with commenced. Compression should not 8 Carefully monitor any increase in the skin flap sloughing off. be started until a correct diagnosis is symptoms such as breathlessness made. In a proportion of patients the 8 Check that fluid is not One of the reasons for poor leg oedema is due to a combination of accumulating in the thigh or groins healing over the tibial crest is the factors, these may include: 8 If well-tolerated and the cardiac relatively poor vascular supply to this 8 Cardiac insufficiency symptoms are stable, compression area. Lack of subcutaneous tissue over 8 Venous disease can be introduced to both limbs the bony prominence may also delay 8 Lymphoedema 8 Levels of high compression may healing. Inappropriate early treatment 8 Certain drug therapies be tolerated in patients with of the wound may influence the 8 Dependency oedema due to controlled heart failure patient’s progress. problems with mobility and 8 If there has been extensive breathlessness on lying flat erythema and blistering, ensure Patients attending A&E may be 8 Respiratory disease all these areas are covered with a poorly assessed. Skin flaps that are no 8 Renal disease non-adherent dressing to prevent longer viable may be replaced rather 8 Liver failure the cotton tubular bandage from than removed, and risk factors such as 8 Peripheral arterial occlusive adhering to the broken skin the presence of venous disease or mild disease. 8 If symptoms worsen, stop ischaemia that will influence healing, compression therapy and refer the may not be identified. Features of cardiac oedema include: patient for a medical assessment. 8 Quick or more insidious Oedema frequently occurs development of oedema Traumatic causes of ulceration following this injury, further influencing 8 The oedema is predominantly Many ulcers begin following a minor the potential for delayed wound soft and pitting, although chronic trauma and it is the underlying disease healing. The following aspects should heart failure may eventually lead process that prevents normal wound be considered when treating these to the fibrotic skin changes seen in healing from occurring. The definition patients: lymphoedema of when a wound becomes an ulcer 8 Any loose dead skin should be 8 The sudden increase in oedema has not been established, although carefully removed ensuring that may cause pronounced erythema epidemiologists frequently refer to a there is no further damage and leakage of fluid from wound that fails to progress over a 8 Any residual haematoma should be the tissues period of four or six weeks (Kantor drained (debridement and removal

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of the haemaotma should only be legs associated with sickle cell anaemia. J carried out by a suitably trained Am Medical Assoc 155: 1487–91 specialist nurse) Edmonds M (2007) The diabetic foot. In: Key Points 8 Antibiotics should be prescribed Morison M, Moffatt CJ, Franks PJ, eds. Leg if there are signs of cellulitis (pain, Ulcers: A problem-based learning approach. 8 Mosby, Elsevier, Edinburgh Compression therapy erythema, increased exudate and remains the mainstay of oedema) Falanga V (2007) Inflammatory ulcers. In: treatment for ulceration Morison M, Moffatt CJ, Franks PJ, eds. Leg 8 The wound should be covered despite some patients’ with a totally non-adherent Ulcers: A problem-based learning approach. Mosby, Elsevier, Edinburgh complex healthcare needs. dressing that allows for exudate to wick away from the wound. International Working Group on the 8 Before compression Dressings such as Mepitel® Diabetic Foot (2003) International consensus on the diabetic foot. International therapy can be used for (Mölnlycke Healthcare) that working group on the diabetic foot. Available patients with diabetes a incorporates silicone are useful. online at: www.iwddf.org/ few key factors need to Mepitel can be left in place to Kantor J, Margolis DJ (2007) Epidemiology. be addressed, such as the allow uninterrupted wound In: Morison M, Moffatt CJ, Franks PJ, exclusion of peripheral healing and only the secondary eds. Leg Ulcers: A problem-based learning arterial occlusive disease, dressing renewed. The open approach. Mosby, Elsevier, Edinburgh the assessment of texture of the dressing allows the Kite A, Powell J (2007) Arterial ulcers: peripheral neuropathy and wound to be inspected at each theories of causation. In: Morison M, the removal of . dressing change Moffatt CJ, Franks PJ, eds. Leg Ulcers: A 8 Control of oedema is an essential problem-based learning approach. Mosby, 8 component of treatment. If there is Elsevier, Edinburgh If the patient has neuropathic foot no evident venous disease, reduced Marshall C (2004) The ankle–brachial compression of < 25 mmHg may pressure index. A critical appraisal. Br J ulceration or evidence of be sufficient to remove oedema Podiatry 7(4): 93–5 haemorrhage beneath a callus, compression should and promote healing Marston WA (2007) Leg ulcers associated 8 Patients with venous disease may with arterial insufficiency : treatment. In: not be applied without require high compression multi- Morison M, Moffatt CJ, Franks PJ, eds. Leg specialist advice. layer bandaging Ulcers: A problem-based learning approach. Mosby, Elsevier, Edinburgh 8 8 Particular care should be taken Compression therapy when applying compression to pad Moffatt CJ, Franks PJ, Doherty DC, Martin may be of some value the area of the tibial crest to avoid R, Blewett R, Ross F (2004). Prevalence of with rheumatoid arthritis leg ulceration in a London population. Q J because of the associated any excess of pressure to this Med 97(7): 431–7 vulnerable area venous insufficiency. 8 In rare cases, if healing does not Morison M, Moffatt CJ, Franks PJ (2007) However, it may cause Leg Ulcers: A problem-based learning excruciating pain in a small progress within a few months approach. Mosby, Elsevier, Edinburgh with conventional treatment, the percentage of patients. patient should be referred to a Mostbeck A, Partsch H, Peschl L (1977) Alteration of blood volume distribution 8 plastic reconstructive surgeon for Up to 70% of people with throughout the body resulting from sickle cell anaemia are consideration of a skin graft. WUK physical and pharmacological intervention. J Vasa 6(2): 137–42 likely to develop a leg ulcer (Serjeant, 2001) and these This article was originally published Oliver S, Mooney J (2002) Targeted in Compression Therapy in Practice, ulcers tend to be slow therapies for patients with rheumatoid to heal and recurrence is edited by Christine Moffatt, published arthritis. Prof Nurse 17(12): 716–20 common. by Wounds UK. To buy a copy go to Olujohungbe A, Anionwu EN (2007) Leg wounds-uk.com/bookstore.shtml ulcers in sickle cell disorders. In: Morison 8 Care should be taken M, Moffatt CJ, Franks PJ, eds. Leg Ulcers: A problem-based learning approach. Mosby, when considering using References Elsevier, Edinburgh compression therapy for patients who have had Burns P, Gough S, Bradbury AW (2003) Pun YLW, Barraclough DRE, Muirdue KD Management of peripheral arterial disease (1990) Leg ulcers in rheumatoid arthritis. cardiac failure. in primary care. Br Med J 326: 584–7 Med J Aust 153(10): 585–7 Cawley MI (1987) Vasculitis and ulceration Ryan S (1995) Nutrition and the in rheumatic diseases of the foot. Ballière’s rheumatoid patient. Br J Nurs 4(3): 132–6 Clinical Rheumatology 1(2): 315–33 Serjeant G (2001) A Guide to Sickle Cell Chernoff AI, Shapleigh JB and Moore CV Disease. A handbook for diagnosis and (1954) Therapy of chronic ulceration of the management. Sickle Cell Trust, Jamaica

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