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An overview of techniques used to measure wound area and volume

If wound area is to be used as an indicator of healing, then it is vital that all measurements are accurate and consistent. This depends largely on the measurement tool used. This paper offers an insight into the available evidence
wound measurement; assessment; wound tracing; planimetrics; computerised stereophotogrammetry
C. Little, RGN, Emergency Medicine Sister;1 J. McDonald, BSc (Hons), Emergency Medicine Staff Nurse;1 M.G. Jenkins, MbChB, FRCS, FCEM,1 Prof P. McCarron, BSc, PhD, MRPSNI, PGCHET; Chair in Pharmaceutical Sciences2 1 Department of Accident and Emergency Medicine, Antrim Area Hospital, Antrim. 2 Department of Pharmacy and Pharmaceutical Scienes, University of Ulster. Email: carollittle58@ googlemail.com

References
1 Nursing and Midwifery Council. The Code: Standards of conduct, performance and ethics for nurses and midwives. www. nmc-uk.org 2 Flanagan, M, Wound measurement: can it help is to monitor progression to healing? J Wound Care 2003: 12; 5, 189-193. 3 Romanelli, M., Dini,V., et al. Clinical evaluation of a wound measurement and documentation system. Wound Research 2008: 20. 4 Fette, A.M. A clinimetric analysis of wound measurement tools. http:// www.worldwidewounds. com/2006/january/Fette/ Clinimetric-AnalysisWound-measurementtoolshtml. Last modied 19-01-2006 5 Plassmann, P., Melhuish, J. M. & Harding, K.G. Methods of measuring wound size: a
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ractitioners have a duty of care to patients to provide best practice and prevent further harm.1 Accurate wound measurement and assessment, therefore, are crucial to prevent harm to the patient. Wound assessment is a complex process that helps to determine the wound aetiology and progression towards healing. Wound measurement is an integral part of this as it provides a baseline from which to measure healing and potentially predict treatment outcomes.2,3 Many measurement methods exist, some simple and practical, and others more suited to clinical research.4 Some, by their nature, are subjective.4 However, an accurate and practical assessment method would include measuring the wound: Length Width Area Volume Circumference (for leg ulcers). Measurement accuracy can be inuenced by the nature of the wound.5 For example: Dening the wound boundary is often difcult The wound appearance can change as a result of a slight body movement for example, when a muscle is exed or the patient changes position The natural curvature of the body The volume of an extensively undermined wound may change with the patients position The location can pose a challenge, especially in wounds sited in areas with a thick covering layer of soft tissue (for example, abdominal wounds): a cavity with a signicant volume may still be apparent even after the wound has healed completely. Clinimetrics provide a framework for the quantitative measurement, assessment and analysis of clinical data.6 It explores six constructs: Accuracy is the data collected accurate? Validity does the tool measure what it is intended to measure? Reliability and consistency do measurements of the same object by two or more individuals differ signicantly?

Reproducibility do repeated measurements yield the same results? Usability do users nd the tool convenient, effective and easy to use? This paper overviews the clinimetrics of wound the various wound measurement tools, based on the available research evidence.

Search strategy
Two reviewers searched Medline, Cinahl and the Cochrane Library, using the terms measurements, wound or measurement, ulcer, assessment, wound and text words, clinimetrics, planimetry, and photography. Both qualitative and quantitative studies were included and no time limit was set. Relevant papers were retrieved, their quality assessed and the reference lists examined for further articles. Non-English papers, papers that were duplicated from other sources and those with references to unpublished work were excluded.

Wound area measurement

Ruler
This calculates the surface area by measuring the greatest length of the wound by the greatest perpendicular width with a ruler or tape measure. However, this assumes that the wound has a geometric surface/shape, such as a rectangle (length x width), circle (diameter x diameter) or oval (maximum diameter x maximum diameter perpendicular to the rst measurement). The use of rulers is, therefore, imprecise for large, irregular or cavity wounds.2 Furthermore, it is subjective and lacks clarity as to the exact points that should be measured.7 Indeed, the accuracy of measurements based on multiplying width by length decreases with larger wound sizes, when the wound area can be overestimated.4 The area of wounds that resemble an ellipse can be calculated using the standard formula (ab length x width x 0.785) can indicate wound surface area,8 although it can underestimate the area of smaller wounds.8
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Tracing
Wound tracing is a popular and practical method of calculating the surface area as it is accessible and easy to learn. Wound margins are traced onto a transparent lm, and the area is calculated either by counting the squares on the tracing or by mechanical/computerised planimetrics.9 Planimetrics measures the area by creating a twodimensional or planar image from a photograph or wound tracing.10 Transparent graph paper is then placed over the image and the number of complete graph squares within the wound boundaries is counted. Clearly, this method is more accurate than approximation. Digital planimetry gives greater precision11 and has both inter-rater and intra-rater reliability, depending on the accuracy of the initial wound tracing.11 Inter-rater reliability is the extent that ratings by two or more individuals agree; intrarater reliability is the extent of agreement between ratings by the same individual at different time points. This is calculated using the intraclass correlation coefcient (ICC). A value of r=0.7 or above is considered acceptable. Richards et al.12 found that the reproducibility (intra-rater reliability) of computer planimetry (Mouseyes)13 was very high at 0.99, based on three consecutive measurements of 192 tracings of diabetic foot ulcers. Accuracy was assessed by comparing the computer planimetry with another planimetric method, regarded as the gold standard by the authors; a close correlation was observed between the two (r=0.99). In contrast, manually counting only complete squares unside the tracing led to unacceptable errors, although counting complete and partially included squares gave fair results. While tracings can give a visual of wound progress, identifying the wound boundaries is difcult, affecting reliability and accuracy.4 In addition, inter-rater errors occur due to different tracing techniques and body curvatures.14 Visitrak (Smith & Nephew) calculates area based on tracing and planimetrics. A study testing the efciency and convenience of the system found high intraand inter-rater reliability (r=0.99, based on 10 pressure ulcers). Concurrent validity, which demonstrates whether a measure correlates well with other validated measures taken at the same time in this case with digital planimetry was also assessed. The ICC for this was 0.99, based on 30 PU measurements.15 Gethin and Cowman compared acetate tracings (counting both complete and partially included squares) with Visitrak when used on 50 supercial leg ulcers, of which 50% were <10cm2. No signicant difference was reported between the two methods for ulcers <10cm2. However, the difference was signicant for ulcers >10cm2 (p=0.008). The authors concluded that acetate provides a good indicator of
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Table 1. Summary of methods used to calculate wound area

Method Ruler based Advantages Highly correlated to more accurate methods Fast, easy to learn, inexpensive Disposable

Disadvantages High standard deviation of measurements Measurements must be made under the same conditions Makes contact with wound Underestimates area and volume

Transparency tracings

Fast, easy to learn, inexpensive Tracing in sequence is easy to compare Graphic record

Counting methods are time consuming Following the body curvatures accurately is difcult Makes contact with wound Dening the wound edges precisely is difcult

Photography

Visual record Relatively inexpensive No contact with wound

Poor repeatability No instant results Inaccurate results when wound surface is curved or not fully visible to camera

wound size, but that digital planimetry is much more precise.7 In an evaluation of 16 patients with diabetic foot ulcers, Shaw et al.8 found that Visitrak was quick, easy and inexpensive, but did not accurately measure small wounds (<25mm2) (p<0.001, based on a one-sample t-test).

Photography
Measuring wound area using tracings from photographs avoids direct wound contact and provides a photographic record. In the community setting, photography is a quick and effective aid to assessing and monitoring the effectiveness of treatment.16 However, accuracy is reduced by the need to scale the photographs and by curvature of the wound area.5 Furthermore, it is difcult to photgraph a wound if it parts of it are not entirely visible to the camera. In clinical practice, this method has poor repeatability. Scaled photography is a two-dimensional method of assessment whereby a special scanner processes the image to include a scaled ruler alongside it. The ruler is used to calculate the length and width, and express these as a simple measurement. This can be useful for comparison but there is potential for magnication errors (where the size being distorted during the re-scaling process).17 In addition, if the wound is curved the camera will not capture this image accurately. Table 1 outlines the advantages and disadvantages of the methods used to calculate wound area.

comparative study. Ostomy Wound Management 1994: 40, 50-52. 6 Feinstein, A. R. An additional basic science for clinical medicine: IV. The development of clinimtetrics. Am Intern Med 1983: 99; 6, 843-848. 7 Gethin, G. & Cowman, S. Wound measurement comparing the use of acetate tracings and Visitrak digital planimetry. J Clinic Nurs 2006: 15, 422-427. 8 Shaw, J., Hughes, C.M. et al. An evaluation of three wound measurement techniques in diabetic foot wounds. Diabetes Care 2007: 30; 10, 2641-2642. 9 Moore, K. Using wound area measurement to predict and monitor response to treatment of chronic wounds. J Wound Care 2005: 14; 5, 229-232. 10 Nuade, L. Wound measurement: the full picture. Professional Nursing Today 2007: 11; 1, 28-30. 11 Gethin, G. & Cowman, S. Wound measurement: the contribution to practice. EMWA Journal 2007: 7; 1 26-28. 12 Richards, J.L., Daures, J.P. & Parer-Richard, C. Of mice and wounds: reproducibility and accuracy of a novel planimetry program for measuring wound area.
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Table 2. Summary of methods for volume measurement

Method Ruler based Advantages Fast Inexpensive Easy to learn

Disadvantages

Invasive Inaccurate

A comparison of wound tracings, digital measurements using photographs and the Kundin gauge, used to measure 36 venous leg ulcers and 37 PUs, found that the Kundin gauge was the least reliable and produced the highest standard deviations as it had to be placed consistently over the same location of the open wound bed.21

Casts

Moulds provide records Inexpensive Easy to learn Does not stick to wound or equipment

Produces some errors Invasive

Saline and alginate casts

Volume can be assessed by covering a wound with a transparent lm dressing and injecting saline from a calibrated syringe.17 The amount of saline used equates with the wound volume.5 Accuracy is determined by the practitioners ability to inject exactly the amount of saline needed for the adhesive lm to match the former undistorted surface of the skin.5 Furthermore, there is a risk that the wound may absorb the saline solution and that patients may nd removal of adhesive lm painful. Alginate casts are an alternative method of measuring wound volume. This is achieved using an alginate impression material, such as is commonly used in dentistry to take impressions of the oral cavity. A powdered alginate material, such as Jeltrate (Dentsply Caulk) is mixed with water to make a paste, poured into the wound and removed when set (between 1.5 and three minutes). The volume of the cast is calculated by dividing its weight by the density of the material (1.13g/cm3 for Jeltrate). However, this method is invasive and can produce user errors. Both the saline and alginate cast have a tendency to overestimate the real volume. This is probably because practitioners tend to ll the wound as fully as possible, thus applying too much material.5,22 Anecdotal evidence suggests these methods are not widely used. There appears to be no rigorous studies on their use.

Saline

Inexpensive

Messy Inaccurate Wound absorbs saline Invasive

Stereophotogrammetry

Very accurate Non-invasive Photographic record

Time-consuming Expensive Trained operator required Limited eld of view

Structured light

Accurate Non-invasive Photographic record Fast

Limited eld of view Some training required Expensive (but less so than sterephotogrammetry)

Wounds 2000: 12; 6, 148-154. 13 Taylor, R.J. Mouseyes: an aid to wound measurement using a computer. J Wound Care 1997; 6: 3, 123-126. 14 Kator, J. & Margolis. Efcacy and prognosis value of simple wound measurements. Archives of Dermatology 1998: 35; 2, 82-91. 15 Sugama, J., Matsui,Y., Sanada, H., et al. A study of the efcacy and convenience of an advanced portable wound measurement system (VISITRAK). J Clin Nurs 2007: 16, 1265-1269. 16 Clarke, G. Recording wounds: Polaroids new medically designed cameras. Brit J Com Nurs 2000: 5; 11, 578-580. 17 Berg, W., Traneroth, C., Gunnasson, A., Lossing, C. A method for measuring pressure sores. In: Fette, A.M. A clinimetric analysis of wound measurement tools. http://www. worldwidewounds. com/2006/january/Fette/ Clinimetric-AnalysisWound-measurementtoolshtml. Last modied 19-01-2006.

Wound volume measurement

Most of the tools discussed above determine wound area but do measure wound volume. However, volume is an important indicator of healing in cavity wounds where healing begins from the base and the area remains unchanged. Tools that measure both volume and area are therefore required.

Kundin gauge
The Kundin gauge18 is an inexpensive, disposable, three-dimensional ruler that measures the length, width and depth of a wound, enabling calculation of both the area and volume. Area (A) is calculated by A = length x breadth x 0.785 and volume (V) by V = A x depth x 0.327. Its main disadvantage is that the area and volume can be underestimated in irregular wounds with underlying cavities.19 Langemo et al.20 compared the Kundin gauge with stereophotogrammetry, which uses optics to measure the three-dimensional coordinates of points on an object. Twenty-four raters, of whom all but two were registered nurses, used the two devices to measure wound volumes of a L-shaped and a pear-shaped plaster of Paris wound model. The results showed that stereophotogrammetry had the smallest standard of error, although the inter-rater reliability of average readings was the same for the two methods (ICC 0.98).

Structured light
This approach involves the use of a device that combines a digital camera, an image-processing computer and strips of light. The light is used to create a three-dimensional model of the wound. Such devices can measure area, circumference and depth. One such tool gradually gaining recognition for its accuracy in measuring wound area and volume is SilhouetteMobile (ARANZ Medical, Christchurch, New Zealand). This is a secure, portable, hand-held, non-contact device for measuring and documenting wound surface area and depth. The device comprises a camera attached to a mobile computing device (known as a PDA). The practitioner traces the wound margin with a stylus on the PDA screen and the wound area is then calculated. In addition, two laser beams emitted from the camera create a threedimensional model of the wound, thus compensatJ O U R N A L O F WO U N D C A R E V O L 1 8 , N O 6 , J U N E 2 0 0 9

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ing for the skin curvature and allowing wound depth to be measured. The wound volume is then determined from these two measurements. Romanelli et al.23 tested the reproducibility and intra- and inter-rater reliability of this device when used by two nurses to assess wound size in 30 patients with VLUs. No statistically signicant differences were found between the scans performed by the two nurses. Intra- and inter-rater reliability was high (>0.80). The mean SD time taken to complete a full scan to calculate area and depth was 2.6 1.2 minutes. There are very few accounts of this device in the peer-reviewed published literature, although Khashram used it to determine the exact wound area before swabbing and calculating the median log10 CFU/cm2.24 As far as we are aware, the device is not widely used in the UK.

based on stereophotogrammetry. It records two images from slightly different view points to generate a stereo pair and then computer software scans both images and computes the wound dimensions.26 It achieves a precision of about 5%,5 although user reliability is yet to be studied, and the ability to dene wound margins in certain cases may be problematic. We intend to investigate this further in a research study. Table 2 summarises the advantages and disadvantages of wound volume measurement methods.

Discussion
Unfortunately, no one method of wound assessment suits all purposes.27,28 Those used in research are generally the most expensive and complex, although they are more likely to produce the most accurate results.4 Simple tools may have a number of disadvantages, but digital planimeters provide reliable and precise calculations of wound area. Wounds are often assessed subjectively, making it difcult to relate baseline and healing measurements. This emphasises the need to develop standardised methodology.10 The growing demand for evidence-based practice, which aims to achieve optimum treatment outcomes and cost-effectiveness, has increased the need to amass a reliable body of knowledge so that wound healing interventions can be compared and contrasted through accurate interpretation of results.29

Computerised stereophotogrammetry
Originally developed for land surveying, computerised stereophotogrammetry uses two pictures of the same area taken from different positions to produce a three-dimensional image. A computerised matching algorithm searches for corresponding points in the two images and then computes the height of each point, based on the distance between corresponding points in the two pictures. This method was found to be extremely accurate, but due to the amount of equipment necessary not very practical in a clinical environment.25 An additional obstacle is the need to develop the photographs before the 20-minute manual scanning process may begin. The MAVIS II, which was developed by the Medical Imaging Laboratories at the University of Glamorgan, measures the dimensions and colour of open wounds. It is a hand-held, non-contact, relatively inexpensive wound-measurement device

Conclusion
No method of wound measurement is perfect. Precise wound measurement is only worthwhile if accurately documented and communicated to the multidisciplinary team. Practitioners must consider the clinical relevance of the information recorded and act upon it.

18 Kundin, J.I. A new way to size up a wound. Am J Nurs 1989: 89; 2, 206-207. 19 Scott, O.,Yang, S. & Ballard, K. Diagnostic and assessment of applications. In: Kitchen, S., Bazin, S. & Clayton, E.B. (Eds) Electrotherapy: Evidence Based Practice. Elsevier Health Sciences 2002: 19, 301-312 20 Langemo, D.K., Melland, H., Olson, B. & Hanson, D. Comparison of 2 wound volume measurement methods. Adv Skin Wound Care 2001: 14, 190-196. 21 Thomas, A.C. & Wysocki, A.B. The healing wound: a comparison of 3 clinically useful methods of measurement. Decubitus 1990: 3; 1, 18-25. 22 Covington, J.S., Grifn, J.W., Mendius R.K. et al. Measurement of pressure ulcer volume using dental impression materials: suggestion from the eld. Physical Therapy 1989; 69: 8, 690-694. 23 Romanelli, M., Dini,V., Rogers, L.C. et al. Clinical evaluation of a wound measurement and documentation system. Wounds 2008; 20: 9, 258-264. 24 Khashram, M., Huggan, P., Ikram, R. Effect of TNP on the microbiology of venous leg ulcers: a pilot study. J Wound Care 2009; 18: 4, 164-167 25 Jones,V. Acute and chronic wound healing. In Baranoski, S. (ed.) Wound Care Essentials. William & Wilkins, 2003. 26 Jones, C.D., Plassmann, P., et al. Good practice guide to the use of MAVIS II. Medical Imaging Research Unit Technical Report TR07-06. University of Glamorgan. 2006. 27 Hibbs, P. The economics of pressure ulcer prevention. Decubitis 1985: 1; 3, 32-39. 28 Russell, L. The importance of clinical documentation and classication. Brit J Nurs 1999: 8; 20, 1342-1354. 29 Devet, H, C., Terwee, L. B., Bouter, L.M. Current changes in clinimetrics. J Clin Epidemiol 2003: 56; 12, 1137-1141.

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