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Side effects of compression stockings: A case report

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Side effects of compression stockings: A case report

Abstract

Compression stockings play an important role in the management of venous disease, venous ulcers, and preventing thromboembolic disease of the deep venous system in the legs1. Most patients admitted to hospital are automatically at a higher risk of developing thromboembolic disease and should therefore receive appropriate prophylaxis2. Although the application of compression stockings can appear simple, it must be remembered that inappropriately worn stockings have the potential to cause significant problems. Unevenly distributed and excess pressure may break the skin, especially in older, malnourished patients and those with thin, brittle skin. Here we present the case of an older male who was referred to a local plastic surgery service for the management of a pressure sore on the anterior aspect of his left lower leg as result of compression stocking application for the treatment of venous ulcer disease. Although an extreme case, it highlights the importance of careful assessment, application, and monitoring of compression stockings. The patient is an 76-year-old male who lives alone in sheltered accommodation and mobilises with the aid of a zimmer frame. His past medical history includes type II diabetes and venous disease. He was initially referred to the vascular surgeons in …
Side effects of compression stockings:
a case report
Bernard F Robertson, Collette H Thomson and Haroon Siddiqui
Clinical Intelligence
316 British Journal of General Practice, June 2014
INTRODUCTION
Compression stockings play an important
role in the management of venous
disease, venous ulcers, and preventing
thromboembolic disease of the deep
venous system in the legs1. Most patients
admitted to hospital are automatically at a
higher risk of developing thromboembolic
disease and should therefore receive
appropriate prophylaxis2. Although the
application of compression stockings can
appear simple, it must be remembered
that inappropriately worn stockings have
the potential to cause significant problems.
Unevenly distributed and excess pressure
may break the skin, especially in older,
malnourished patients and those with thin,
brittle skin. Here we present the case of
an older male who was referred to a local
plastic surgery service for the management
of a pressure sore on the anterior aspect of
his left lower leg as result of compression
stocking application for the treatment of
venous ulcer disease. Although an extreme
case, it highlights the importance of careful
assessment, application, and monitoring of
compression stockings.
CASE DESCRIPTION
The patient is an 76-year-old male who
lives alone in sheltered accommodation
and mobilises with the aid of a zimmer
frame. His past medical history includes
type II diabetes and venous disease. He
was initially referred to the vascular
surgeons in 2002 with a venous ulcer on
the medial aspect of his left ankle and
it was recommended that he be treated
conservatively with grade 3 compression
stockings (40–60 mmHg). At that time it
was noted that he was overweight and
had chronic oedema of both legs and feet.
Initially the stockings were beneficial and
the ulcer resolved, however, their continual
use subsequently caused problems. The
patient developed a new ulcer on the
anterior aspect of his shin, proximal and
lateral to the original ulcer, thought to be as
a result of pressure from the compression
stockings. This new ulcer was initially
managed in the community by the district
nursing team. However, they continued to
apply the compression stockings on top of
the dressings and subsequent deterioration
was noted. After 10 months of conservative
treatment, with continued deterioration
and no progress observed, the patient was
reviewed by his GP and referred to the local
plastic surgery service for further advice.
When the patient presented to our unit for
his initial assessment, he had the stockings
applied over the wound. It was noted that
the stockings were rolled at the point of
the ulcer, creating increased pressure in
this area. The skin, subcutaneous fat and
extensor retinaculum of the anterior lower
leg and foot had been eroded with the
wound measuring 5 x 10 cm (Figure 1).
When the patient held his foot in a neutral
position his necrotic tibialis anterior tendon
was clearly visible and bow stringing out in
front of his ankle (Figure 2). Wound swabs in
the community had grown
Staphylococcus
aureu
s, however the wound was not clinically
infected with no surrounding cellulitis.
Initial management included intravenous
flucloxacillin and careful pre-operative
assessment for a debridement under
general anaesthesia. The surgical
debridement removed all non-viable tissue,
including the necrotic, exposed tibialis
anterior tendon (Figure 3). The wound was
not suitable for immediate skin grafting.
Negative pressure wound therapy was
applied for 12 days until microbiology swabs
were clear and sufficient healthy granulation
tissue was present. Thirteen days post-
debridement the patient underwent
a skin grafting procedure. His recovery
was slowed by a catheter-related urinary
sepsis, however he went on to make a good
recovery. He was transferred to his local
district hospital for rehabilitation 3 weeks
following admission and discharged from
there with a package of care 2 weeks later.
Bernard F Robertson, BMed Sci, MRCS, CT2
plastic surgery; Collette H Thomson, MSc,
MRCS, ST3 plastic surgery; Haroon Siddiqui,
FRCS (Plast), consultant plastic surgeon,
Plastic Surgery Department, James Cook
University Hospital, Middlesbrough.
Address for correspondence
Bernard F Robertson, Plastic Surgery
Department, James Cook University Hospital,
Marton Road, Middlesbrough, TS4 3BW.
E-mail: br86@me.com
Submitted: 19 January 2014; Editor’s
response: 1 February 2014; final acceptance:
9 February 2014.
©British Journal of General Practice 2013;
63: 316–317.
DOI: 10.3399/bjgp14X680341
British Journal of General Practice, June 2014 317
He was last seen in the community by the
plastic surgery specialist nurses 2 months
post-surgery where it was noted that all his
wounds had healed and he was discharged
from our care.
DISCUSSION
This case highlights the importance of
ensuring that patients are appropriately
assessed and monitored for suitability for
compression stockings and that measures
are taken to ensure they are worn
appropriately. If not managed accordingly
compression stockings may cause
unintended harm as demonstrated by this
case, which represents the more severe
end of the spectrum. It is of particular
importance to ensure that there are no
folds in the fabric, allowing even distribution
of pressure throughout the limb and to
avoid creating a focus of higher pressure
over one specific area. If adverse effects
from wearing compression stockings are
identified, early intervention, which may
include removing the source of the problem
and liaison with other teams, may help
limit the extent of the complication and
reduce the need for surgical intervention.
Early discussion with the GP, followed by
referral to tissue viability nurse should be
undertaken if the patients fail to respond to
compression therapy.
This case also acts as a reminder that
although common things are common, not
all ulcers in the legs are vascular in origin.
When treatment (such as compression
stockings) does not appear to be working,
other causes for problems should be
investigated.
There have been a few case reports
published that demonstrate some side
effects of compressions stockings with
two reports of nerve injuries3,4 and one
report of bilateral pressure sores in both
popliteal fossae of a paraplegic patient.5
This patient developed acute linear tears
along the line of compression stockings
over a 2-week period during hospital
admission. The patient’s pressure sores
were successfully managed conservatively,
with discontinuation of the compression
stockings and regular dressings.
CONCLUSION
While an almost everyday intervention,
compression stockings are not without
potential risks and therefore require
correct application and close monitoring,
especially in those who are at greater risk
of skin damage. Early action is vital when
complications do occur to limit the extent
of injury and degree of treatment required,
and when problems are not responding to
the treatment, reassessment is necessary.
Patient consent
The patient has consented to publication of
this article and the associated images.
Provenance
Freely submitted; not externally peer
reviewed.
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REFERENCES
1. Partsch H, Flour M, Smith PC; International
Compression Club. Indications for
compression therapy in venous and lymphatic
disease consensus based on experimental
data and scientific evidence. Under the
auspices of the IUP.
Int Angiol
2008; 27(3):
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2. Edelsberg J, Hagiwara M, Taneja C, Oster
G. Risk of venous thromboembolism among
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Am J
Health Syst Pharm
2006; 63(20 Suppl 6):
S16–S22.
3. Hirate H, Sobue K, Tsuda T, Katsuya H,
Peripheral nerve injury caused by misuse of
elastic stockings.
Anaesth Intens care
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4. O’Brien C. Common peroneal nerve injury
as a possible sequelae of poorly fitting
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Ann
Plas Surg
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5. Ong JC, Chan FC, McCann J. Pressure
ulcers of the popliteal fossae caused by
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Ir J
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Figure 1. Right lower leg ulcer with visible tibialis
anterior.
Figure 2. Exposed necrotic tibialis anterior tendon. Figure 3. Wound post debridement.
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