Abstract
Background
While limited information is available, it is possible that high or low sub-bandage pressures cause injury with external coaptation. Fiberglass casting tape is a common splinting material that is custom made for the first bandage and reused in subsequent bandage changes. The aim of this preliminary study was to determine sub-bandage pressure changes in canine hindlimbs between initial splint placement and replacement of the bandage by a different person. The hypothesis was that there would be a clinically meaningful change in sub-bandage pressures with reapplication of the splint in at least one location. Sub-bandage pressures were measured at five different anatomic locations on each of 11 canine hind limbs with dogs standing and in lateral recumbency after customizing a fiberglass lateral tarsal splint for each dog. A second clinician then reapplied the bandage, reusing the same fiberglass splint. Second bandages failed if there was a change in pressure of 20 mmHg at any location.
Results
Ten of 11 bandages failed (90%). All but one location failed due to increases in pressure. There were significant changes between lateral recumbency and standing pressures, but there was no consistent pattern of these changes among the dogs.
Conclusion
There are changes in sub-bandage pressures when the splint is reused in 90% of bandages. In addition, changes in pressure occur unpredictably when transitioning from lateral recumbency to standing. Further study of the relationship of sub-bandage pressures to bandage complications is vital to help establish safe ranges and inform bandaging improvements.
Keywords: Bandaging, External coaptation, Sub-bandage pressures, Splinting
Introduction
External coaptation is routinely utilized for the management of fractures, luxations, wounds, and postoperative swelling in veterinary orthopedics. The use of these bandaging strategies is not benign and can result in varying degrees of tissue injury. In one retrospective study, 63% of patients fitted with a cast developed a soft tissue injury, and of those, 40% required continued veterinary interventions [1]. Pathologies associated with bandaging include pressure sores, swelling, erythema, superficial abrasions, and dermatitis [1–5]. Lameness, full thickness lesions, infection, sloughing of the epidermis/dermis, and neuropraxia may also occur, requiring additional management [1–5]. These more complex complications may require further treatment such as open wound management, surgical debridement, skin grafts, and in more severe cases, arthrodesis, amputation, and even euthanasia [1, 2, 5]. The costs associated with managing these conditions can exceed the cost of the original orthopedic procedure with a range of 17% the cost for minor complications to 125% for major complications in one retrospective study [1]. While bandage-associated injuries can be severe, they are only detected by owners approximately 20% of the time [1]. This insensitivity to detecting coaptation complications along with the morbidity and financial burden associated with these injuries can be clinically substantial.
The veterinary literature suggests that areas over bony prominences have a higher tendency to exhibit bandage sores. (1, 3, 6–7) This may be due to additional pressure at these prominences. Pressure ulcers are defined as areas of localized soft tissue ischemic necrosis caused by prolonged external pressure higher than the capillary pressure [6]. These injuries have a complicated etiopathogenesis [2, 6].
In humans, an external pressure source of 16–33 mmHg is enough to overcome the capillary pressure which in combination with other risk factors including time, shear force, friction, moisture, decreased/absent sensation, over/undernutrition, anemia, edema, and acute illness can cause anoxic injury [6]. Previous research involving pressure splint application to the hindlimbs of greyhounds has shown that arterial blood flow is decreased by 40% with a 20 mmHg increase in bandage pressure [8]. Such a reduction in oxygen delivery is likely a contributing factor to sore formation and therefore 20 mmHg could be considered a clinical difference in pressure. However, areas over bony prominences seem to handle much higher external pressures; for example, pressures over the human ischial tuberosity can exceed 100 mmHg without issue. (9–10) The amount of time that tissues can withstand high pressure is unknown; thus, changes in pressure occurring at different positions may also influence sore formation.
In veterinary medicine, experienced bandagers create pressures of approximately 85 mmHg over bony prominences when placing custom splints [11]. It is common at many hospitals for bandaging to be performed by different personnel throughout a treatment period, and custom fiberglass splints placed at the first bandage application are usually reused at each bandage change. When replacing a bandage, it can be difficult to replicate the fit between the limb, padding, and original shape of the splint even with minor modifications. The reapplication of original splints could arguably create pressure points greater than 85 mmHg that may develop into secondary soft tissue injuries [1]. To our knowledge, pressure changes with the reuse of a custom fiberglass splint have not been investigated. While the same general principles are utilized when placing bandages, there is variability among bandagers [11]. Differences in pressure could be a cause of pressure points leading to ischemic injuries in external coaptation with rigid fiberglass splinting.
Our primary objective was to evaluate the pressure change between the original customized splint and the splint reapplied by a second person. We hypothesized that there would be at least one area on the hindlimb where the sub-bandage pressure would change by a clinically relevant amount (20 mmHg) after reapplication of a customized splint as measured in lateral recumbency one hour after bandage placement. (6, 8–9) As a secondary objective, pressure changes were compared between lateral and standing positions. We hypothesized that there would be at least one area on the hindlimb where, similarly, sub-bandage pressure would change by 20 mmHg from lateral recumbency to standing.
Results
Eight castrated male and 3 spayed female dogs were enrolled. None of the dogs in this study needed to be excluded based on the exclusion criteria. The median age of the dogs was 6 years, with a range of 1.5–11.5 years. The average weight of the dogs was 31.5 kg (SD +/- 11.8 kg). There were 4 mixed breed dogs, 2 Bullmastiffs, 2 German Shepherd dogs, 1 German Shorthaired Pointer, 1 Labrador Retriever, and 1 American Staffordshire Terrier in this study. The first bandage was placed on 6 dogs by bandager 1 and on 5 dogs by bandager 2. There were 7 left hind limbs splinted and 4 right hind limbs splinted. After splinting, the average angle of the hind limb while in lateral recumbency was 154.8° (SD +/- 7.0° with a range of 143°-165°), with a median splint angle of 155° for both bandagers. There were 4 splints in the study that could not be replaced without modifications: for dogs 5 and 6, the splints had to be trimmed proximally and distally; for dogs 8 and 11, the splints were trimmed distally.
Mean sub-bandage pressures in standing and lateral recumbency are expressed in Table 1. The pressure transducer malfunctioned at location 5 (the calcaneus) in dog 2, so that measurement was not included in the analysis.
Table 1.
Mean (+/- standard deviation) pressures in mmHg of each measured location (P1-P5) 1 h after placement in lateral recumbency and standing position for initial bandage placement (B1) and replacement (B2). Metatarsophalangeal joint (MPJ)
| P1 - Lateral MPJ | P2 - Medial MPJ | P3 - Cranial metatarsus | P4 - Lateral malleolus | P5 - Caudal calcaneus | |
|---|---|---|---|---|---|
| B1 Stand | 67.00 (+/- 3.32) | 88.86 (+/- 20.34) | 94.05 (+/- 16.08) | 70.27 (+/-18.27) | 53.27 (+/-13.06) |
| B1 Lateral | 78.86 (+/-14.24) | 82.23 (+/-16.50) | 69.00 (+/-12.71) | 62.86 (+/- 11.34) | 71.32 (+/-18.46) |
| B2 Stand | 97.55 (+/-16.83) | 114.05 (+/-11.42) | 81.09 (+/-16.31) | 71.41 (+/-20.66) | 103.41 (+/-39.46) |
| B2 Lateral | 90.50 (+/-12.37) | 101.00 (+/-11.59) | 82.36 (+/-14.09) | 77.95 (+/-17.55) | 89.00 (+/-26.07) |
Based on our criteria, 10/11 bandages failed. There was no predictable location at which the bandages failed. All locations failed as a result of an increase in pressure with the exception of dog 9 at the lateral aspect of the metatarsophalangeal joint, which failed due to a decrease in pressure. (Table 2)
Table 2.
Locations of failure of each dog in the study as a result of an increase in pressure of 20 mmHg
| Dog number | Pass or Fail | Location of Failure |
|---|---|---|
| 1 | F | P5 |
| 2 | F | P1, P3 |
| 3 | P | |
| 4 | F | P3, P5 |
| 5 | F | P4 |
| 6 | F | P1, P2, P3 |
| 7 | F | P2, P4 |
| 8 | F | P1, P2 |
| 9 | F | P1a P4, P5 |
| 10 | F | P2, P4 |
| 11 | F | P2, P3, P4, P5 |
aIndicates a failure by a decrease in pressure of 20 mmHg
There was no difference in sub-bandage pressures between clinicians for the first bandage placement at any location except the lateral metatarsophalangeal joint, where one clinician had a mean pressure of 86 mmHg, and the other had a mean pressure of 67 mmHg. For bandage 2, there was no difference between pressures at any time point.
For our secondary objective, there were statistically significant pressure differences between standing and lateral positions, but these changes were not predictable and were not consistent among the dogs across sensor locations (Figs. 1 and 2). Pressures after initial bandage placement were significantly higher in lateral recumbency compared to standing for the lateral metatarsophalangeal joint and the calcaneus (P = 0.01 and 0.02, respectively). Pressures at the cranial metatarsus for initial bandage placement were higher in lateral recumbency than in standing (Fig. 1; P = 0.001). After bandage replacement, the pressures at the medial metatarsophalangeal joint were higher in standing than in lateral recumbency (Fig. 2; P = 0.02).
Fig. 1.
Bandage 1 changes in pressure from lateral recumbency to standing. Mean (+/- standard deviation) changes in pressure in mmHg of each measured location 1 h after placement in lateral recumbency and standing position for initial bandage placement. Positive values indicate higher relative pressure when in lateral recumbency, and negative values indicate lower relative pressures when in lateral recumbency. Metatarsophalangeal joint (MTP); Metatarsal (MT). * Indicates that the pressure difference from lateral recumbency to standing was significant (P < 0.05)
Fig. 2.
Bandage 2 changes in pressure from lateral recumbency to standing. Mean (+/- standard deviation) changes in pressure in mmHg of each measured location 1 h after placement in lateral recumbency and standing position for bandage replacement. Positive values indicate higher relative pressure when in lateral recumbency, and negative values indicate lower relative pressures when in lateral recumbency. Metatarsophalangeal joint (MTP); Metatarsal (MT). * Indicates that the pressure difference from lateral recumbency to standing was significant (P < 0.05)
Discussion
In this study, we confirmed our hypothesis that sub-bandage pressures would vary by greater than 20 mmHg on at least one area of the hindlimb between applications using the same custom rigid fiberglass splint. It is worth noting that the bandages failed by an increase in pressure (21/22 sites) rather than a decrease in pressure. While unclear, based on current theories proposed in human and veterinary literature, higher sub-bandage pressures may increase the risk of ischemic bandage injuries [2, 6]. There were no specific locations at which the second bandage failed consistently. The control in this study, the central cranial surface of the metatarsal bones, had fewer failures compared to the other chosen points, but surprisingly, it still increased in pressure by 20 mmHg in 3 dogs. This again suggests that bandage complications are indeed multifactorial, and the entire bandage may be tighter after reapplication.
There are multiple potential reasons why the second bandage could not be replaced with similar pressure profiles. First, when replacing a preformed splint, it is difficult to replicate the conditions of the original bandage (i.e. joint angle, amount and placement of bandage material, pressure applied when applying bandaging material, layers utilized in the bandage placement, and repositioning of the fiberglass splint). As these factors are not controlled in a clinical setting, they were not standardized in this study. To accomplish this study, 4 splints had to be modified to be able to replace them on the limb. This is common in clinical practice. It is possible that more splints would have passed if significant modifications had been performed.
Second, splinting the hock in a more extended position may allow more conformity from replacement to replacement. In this study, the mean splinted angle of the hind limb was 154.8°, which is higher than the true average standing angle of the hind limb of 135–145° [12]. This could be due to the bias of clinicians in this study toward splinting the stifle in slight extension, as this is subjectively easier to do when using fiberglass casting tape in the initial bandage. In this study, the angles were similar among the dogs, but it may be that a different angle makes replacing bandages more uniform, decreasing pressure changes.
The third factor potentially contributing to pressure changes is the person-to-person and dog-to-dog variation. Even among expert bandagers, variation is high [11]. In this study, there was variation between the bandagers. The only location that was statistically different was in the original bandage at the lateral metatarsophalangeal joint. Unfortunately, we cannot separate this phenomenon from the dog-to-dog variation that would influence bandage pressure and placement. Person-to-person variation was limited as much as possible by using two experienced bandagers using the same methodology of bandage placement. Two bandagers were used because in many practices a different clinician or technician performs bandage changes to facilitate scheduling. Further studies elucidating differences between the reapplication of a bandage by the same bandager versus a different clinician are warranted.
Our secondary objective was to explore the relationship between pressure measurements in standing and lateral recumbency. Our primary objective was evaluated in lateral recumbency because dogs are activity restricted when splinted and previous reports measured in this position [11]. However, logically, these positions may differ in pressure with clinical relevance. Initially upon placement of the first bandages, the lateral metatarsophalangeal joint and caudal calcaneus had lower pressures when standing compared to lateral recumbency, but when the bandage was replaced, this trend was not consistent. While there were differences in pressure detected, the pressure differences for the sites chosen in this study were not predictable or consistent. This is evidence that there are changes in sub-bandage pressure at selected points on the hind limb between lateral recumbency and standing; however, these changes are unpredictable. Inexperienced bandagers who apply the bandage too loosely may see a more predictable pattern or a more extreme rise in pressure when standing vs. lateral recumbency [11]. Further studies with larger sample sizes are warranted to establish whether there is a location with repeatable changes in pressure as a result of patient mobility.
Additionally, this methodology has variation in measurement. To minimize the measurement variation, 2 measurements at each location were taken and averaged, the sensors were not dislodged between bandages, and changes in pressure were used rather than the absolute measurement to determine the outcome. The instrumentation utilized in this study is highly accurate in air compression chambers (within 1 mmHg), but it overestimates at low pressures in bandage simulations (20–40 mmHg) [13]. The measurements in this study were within the more accurate range for this instrument (> 40 mmHg).
There are several limitations to this study including small sample size, use of clinically normal dogs, and using a single point measurement rather than measurements over an extended time period. Sample size was determined statistically prior to study start, but in addition to a small number, the dogs were relatively homogenous in size. This limiting the generalizability of the conclusions to all dogs. Changes in limb swelling, gait, utilization of limbs, susceptibility to changes in pressure, and changes in tissue oncotic pressure based on injuries could not be assessed, but may affect measurements. Dogs with orthopedic disease were specifically excluded from this study to avoid introducing additional variation from the disease process. This study could not address all possible mechanisms of bandage injury, but instead focused on pressure changes. These pressure changes may also be different in bandages maintained for days to weeks as in a clinical setting. Last, it may be argued that strictly controlling the bandaged joint angle, amount of cast padding used, and splint modifications is a limitation of the study. However, this trial was designed to mimic a common clinical situation. Ideally, pressure changes could have been measured over time to see if bandage sores occurred in the sensor positions that failed.
Additional studies investigating the difference of sub-bandage pressures utilizing varying external coaptation types including but not limited to fiberglass splint, fiberglass cast, bivalved cast, and thermoplastic splint would further the gap of understanding of normal sub-bandage pressures with different external coaptation materials. Incorporating the forelimb in studies would be beneficial as well to determine if there are significant differences in sub-bandage pressures between the forelimb and hindlimb. Changes in sub-bandage pressure while walking or over the life of the bandage would likely help understand sore formation, but a different type of sensor would be necessary for these measurements.
Conclusion
Overall, our results confirmed our hypothesis that utilizing the same custom rigid splint for bandage changes would result in changes in sub-bandage pressure greater than 20 mmHg at common locations for bandage injuries in the majority of dogs. All changes were increases in pressure except in one dog at one location. It is important to acknowledge that due to the limitations of this study and the population of dogs that these results may not be generalizable to all canine populations and clinical situations.
Although we do not know the absolute pressure threshold for sore formation, these results support the formulation of a randomized, controlled clinical trial in a diverse population of dogs with diverse orthopedic conditions to investigate the incidence of pressure sores between reuse of the original splint and creation of a new custom splint at each bandage change. In addition, further study of the relationship of sub-bandage pressures to bandage complications is also vital to help establish safe ranges and inform bandaging instruction provided during veterinary training.
Materials and methods
The study protocol was approved by the University of Minnesota Institutional Animal Care and Use Committee and informed client consent was collected from the owners of the privately owned dogs used in this study. The animals in the study were released back to the owners after bandaging data were collected. Two clinicians experienced in bandaging (> 100 bandages placed), a diplomat in the American College of Veterinary Surgeons, and a surgical resident, were tasked with either creating a customized splint with fiberglass casting tape on the hock of a dog or performing a bandage change utilizing the previously made splint.
Eleven dogs owned by hospital staff, free of orthopedic disease, and weighing ≥ 20 kg were recruited based on a priori sample size calculation. The number of dogs required was calculated assuming that 80% of dogs would have significant pressure changes (> 20 mm Hg) with 90% confidence and a 0.2 margin of error using the formula for estimating sample size for a proportion. Dogs were excluded if they had acute injuries, did not allow restraint for bandage application, or were noncompliant for the bandage application/changes. The clinicians were instructed to place a splint to stabilize the tarsus at a standing angle.
A random number generator was utilized to determine which individual would place the initial bandage (B1), and the other clinician would perform the bandage change (B2). The clinicians were blinded to the first bandage application preventing them from watching the bandage application by the other clinician. A coin flip was used to determine whether the left or right hind limb was used.
A pneumatic pressure device (PicoPress Compression Measurement System; MediGroup, Melbourne, Australia) was used to measure sub-bandage pressure in this study. Five transducer bladders and conduction tubes were used in accordance with the manufacturer’s previously validated instructions, similar to previous publications [11, 13–17]. Transducer bladders were positioned on the (1) lateral aspect of the metatarsophalangeal joint, (2) medial aspect of the metatarsophalangeal joint, (3) central cranial surface of the metatarsal bones, (4) the lateral malleolus, and (5) caudal aspect of the calcaneus (Fig. 3). Locations 1, 2, 4, and 5 are the most common sites of complications of bandage sores in the canine hind limb [3, 5, 7]. Location 3 was chosen as a control because it is not a common site for hindlimb bandage sores [3, 5, 7]. Each conduction tube was labeled for positioning. The conduction tubes and bladders were taped into position using 1 inch cloth tape, using caution not to compress the bladders or kink the tubing. A 1 inch stockinette (3 M; St. Paul, Minnesota, United States) was placed for extra security and to prevent sensor movement between bandage changes.
Fig. 3.
Image of lateral tarsus with sensor positions. Transducer bladders positioned on the (P1) lateral aspect of the metatarsophalangeal joint, (P2) medial aspect of the metatarsophalangeal joint, (P3) central cranial surface of the metatarsal bones, (P4) the lateral malleolus, and (P5) caudal aspect of the calcaneus
A soft padded bandage with a custom lateral fiberglass splint was placed from the toes to the proximal tibia using the following supplies in order: 3-inch cast padding (Wytex Medline; Mundelein, Illinois, United States), 3-inch stretch gauze bandage (Curity Covidien; Mansfield, Massachusetts, United States), 3-inch custom lateral splint (Vetcast Plus 3 M), 3-inch stretch gauze, and 2-inch self-adhesive bandage wrap (Vetrap 3 M). Each layer was placed with approximately 50% overlap, and applied by the applicant to secure the bandage in place with even tension as clinically practiced. The lateral splint was fashioned by unrolling the fiberglass casting tape from toes to the top of the soft padded portion and back until the roll was empty, and molded to the bandage. A goniometer was utilized to measure the angle of the limb after splint application while in lateral recumbency. For the replacement bandage, the original custom fiberglass was reused as the splint. Minor modifications with utility shears were allowed if necessary to maintain clinical accuracy.
Sub-bandage pressures were measured with the pneumatic pressure device at 1 h after splint application according to manufacturer’s directions. This time point was chosen due to previous research showing that bandages lose pressure over the first hour and then maintain pressure over time [11]. Each dog was allowed to use the hindlimb and walk freely in a confined space no larger than 100 square feet under supervision while waiting. Pressure measurements in both standing and lateral recumbency were performed twice for each location and the average was used for analysis.
Failure of the second bandage was defined as a change in pressure of 20 mmHg at any of the sensor locations from the first to the second bandage as measured in lateral recumbency 1 h after placement. The failure rate is reported as a percentage.
Pressure data were also assessed for differences between the bandaging clinicians which may have influenced the results using a Wilcoxon rank-sum test. Data are reported as mean +/- standard deviation. For the secondary objective, a matched pairs t-test was used to determine the difference between lateral and standing for each time point and sensor site.
Acknowledgements
Special thanks to the UMN VMC staff who contributed their dogs for participation in this study.
Abbreviations
- B1
Initial bandage placement
- B2
Bandage replacement
- MTP
Metatarsophalangeal joint
- MT
Metatarsals
Author contributions
BT – Assisted with experimental design and experimentation/data collection; manuscript composition. KE – assisted with experimental design, experimentation/data collection, abstract composition, and manuscript editing. WGE – Lead experimental design, experimentation/data collection, data analysis, and manuscript editing. All of the authors have read and approved the final manuscript.
Funding
University of Minnesota internal funding.
Data availability
The data generated and analyzed during this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The study protocol was approved by the University of Minnesota Institutional Animal Care and Use Committee and informed client consent was collected from the owners of the privately owned dogs used in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
The data generated and analyzed during this study are available from the corresponding author upon reasonable request.