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SPECIAL FEATURES

Planimetric Measurements 101

Get to know this wound-care tool
By Martin E. Wendelken DPM, RN
Oscar M. Alvarez, Ph.D.
Lee Markowitz, DPM
Christopher Comfort, MD
Lucy Hernandez, NP

Plani-what?
Planimetry is dened as the measurement of plane
surfaces in this case, lesions and wounds on the skin.
In medicine, there are a number of necessary reasons to
measure lesions on the skins surface. Measurements are
used to follow or track changes in the size of lesions or
wounds as practitioners apply a number of medications
or therapies to treat a pathologic condition. Tracking
chronic or acute wounds is particularly important
because it is known that changes in wound surface
area over time can be used as a predictor of
wound closure.1,2,3
ere are a number of methods of determining wound
dimensions. Currently, the most popular method is simple
linear measurements (length = L and width = W). Linear
measurements should be made so that the widest width is
made and the longest length is measured perpendicular to the width line. Area is then calculated by multiplying length by width. Although
simple to perform, it is the least accurate method in that L x W is based on a rectangle while wounds are a variety of shapes. Errors can
exceed 50 percent and higher using this method (Fig.1).
Another method of wound measurement is the tracing of a wound parameter on a transparent acetate sheet. is is better than linear
measurements, but not without its problems. Steam forms below the lm surface, glare blocks visibility of the wound and there is an
increased risk of wound contamination performing tracings (Fig.1). Tracing can also be painful to the patient, and this method takes time to
count the squares (in centimeters) after placing the acetate sheet over a grid to determine wound area. It is very well documented that the
inter-rater reliability of
wound tracings (two people tracing the same
wound) yields large dierences in wound areas. A
recent advancement in
wound tracings provides
for a digital tablet that
counts the number of
squares (in centimeters);
however, a second tracing
over the original tracing
on the device is necessary.
is increases the chance
and risk of errors.
Fig. 1: Left- Wounds are typically measured in centimeters, using a ruler. e wound length and width (perpendicular to the length) are
made. Area is calculated by multiplying the length by the width. Right- Manual tracings are more accurate than linear measurements
but are much harder and time consuming to perform. In addition, tracings can be painful to the patient and have contamination risks.

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Digital photo planimetry

e image obtained has a ruler in the picture, which is then used for easy calibration with the software. Once calibrated, the measurement data is generated by the
computer, captured and added to the image for easy reading. e data generated
can also be saved to a spreadsheet program to calculate percent change in area of
the wound in addition to providing a wound history and/or statistical analysis of
changes in the wound parameters. PDPS has been found to be the best way to
measure both regular and oddly shaped wounds (Fig. 4).

A well-obtained photograph provides excellent documentation of a wound or lesions current status.

Photographs also have the ability to provide a wound
history and act as a wound monitor when serial images
are taken of the same lesion (Fig. 2). e addition of
accurate measurements on photographs adds a new
dimension to this archiving process. Images with measurements can be used as a yardstick to track the
eectiveness of specic treatment regimens. Wound
measurements are used as an objective basis for reimbursement for a variety of dressings, skin replacements,
negative pressure therapy and surgical debridement.
Digital photographys popularity has grown by leaps and
bounds in the past several years and for many is now the
preferred method of acquiring images (versus images on
photographic lm). Digital cameras are easy to use, and
many have wonderful image quality and image size up
to 10 megapixels or more. (Pixel, by the way, is short for
picture element, the basic unit from which a video or
computer picture is made. e more pixels, the higher
the resolution of
the picture.)
Photo digital planimetry
software (PDPS) is now
available and can be
used to perform accurate measurements on
digital photographs.
PDPS mapping of
wounds or lesions is
performed on a computer using a mouse or
touch screen monitor, a
notebook tablet with
pen or USB tablet with
pen. Images of the
lesions are captured
with a digital camera
without regard to distance (as close as possible provides better
images and measurements). Parameters
include length, width,
area, circumference and
depth (added) to calculate volume (Fig. 3).

Reports can be generated for the residents chart (electronic or paper) and can also
be sent to referral sources. ese same reports might be needed for insurance
companies and Medicare for reimbursement purposes. Best of all, unlike tracings,
the data can be veried by others because the original picture is always available
for review. PDPS has been shown to have intra-rater reliability of 98.3 percent, or
less than a 1.7 percent error rate.

Fig. 2- Pictures of wounds can be stored and shown as a series of images, showing
changes in the size of the wound over time.

Fig. 3- Photo digital planimetry software shines when it comes to oddly shaped wounds. Above, an image of oddly
shaped wound (right) and the measured wound using PDPS (left).

References
1. Sheehan P, Jones P, Caselli A, Giurini J, Veves A. Percent change in wound area of diabetic foot ulcers over a
4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003
Jun;26(6):1879-82.
2. Margolis DJ, Allen-Taylor L, Hostad O, Berlin JA. e accuracy of venous leg ulcer prognostic models in a
wound care system. Wound Repair and Regeneration. 2004 Mar-Apr; 12(2):163-8
3. Van Rijswijk L, Polansky M. Predictors of time to healing deep pressure ulcers. Ostomy Wound Management.
1994 Oct;40(8):40-2, 44, 46-8 passim.
4. Alvarez OM, Markowitz L, Booker J, Rogers S, Patel M, Eectiveness of a four-layer compression bandage* and
the modied unnas boot for the treatment of lower leg ulcers in ambulatory patients with chronic venous
disease: a crossover study involving 80 patients. Abstract presented at the 18th Annual Symposium on
Advanced Wound Care. San Diego, Calif; 2005.
5. Wendelken M, Alvarez O, Markowitz L, Comfort C, Waltrous L. Key insights on mapping wounds with
ultrasound. Podiatry Today. 2006;19(7):70-74.
6. Alvarez O, Wendelken M, Markowitz L, Comfort C, Waltrose L. Wounds measured from digital photographs
using photo-digital planimetry software: validation and rater reliability. Oral abstract presented at the 19th
Annual Symposium on Advanced Wound Care. San Antonio, Texas; 2006.

An attorneys view on photographic

wound documentation
Attorneys often disagree when advising longterm care facilities regarding the use of photos for wound documentation. However,
there are times when photographic wound
documentation can be very useful to a facility. Photos can be helpful in documenting the
exact measurements of wounds present on
admission. A long-term care facility can
precisely identify the number, extent and
location of the wounds that a resident presents with at admission. e progress of those
wounds can also be well documented with
photos. e facility's wound documentation
policies and procedures must be very specic
regarding the appropriate times for photographic documentation. A facility can place
itself at increased legal risk without appropriate policies and procedures related to photographic evidence. Consult your legal counsel
prior to implementing a photographic policy
for wounds.
-Janet K. Feldkamp RN, BSN, LNHA, JD

Fig. 4- Above is a sample of a foot wound over the dorsal aspect of the toes. In comparison to traditional
measurements, PDPS provides a clear visual indicator that allows a clinician to calculate the wounds exact
surface regardless of shape.

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Page 30

Digital photo planimetry

e image obtained has a ruler in the picture, which is then used for easy calibration with the software. Once calibrated, the measurement data is generated by the
computer, captured and added to the image for easy reading. e data generated
can also be saved to a spreadsheet program to calculate percent change in area of
the wound in addition to providing a wound history and/or statistical analysis of
changes in the wound parameters. PDPS has been found to be the best way to
measure both regular and oddly shaped wounds (Fig. 4).

A well-obtained photograph provides excellent documentation of a wound or lesions current status.

Photographs also have the ability to provide a wound
history and act as a wound monitor when serial images
are taken of the same lesion (Fig. 2). e addition of
accurate measurements on photographs adds a new
dimension to this archiving process. Images with measurements can be used as a yardstick to track the
eectiveness of specic treatment regimens. Wound
measurements are used as an objective basis for reimbursement for a variety of dressings, skin replacements,
negative pressure therapy and surgical debridement.
Digital photographys popularity has grown by leaps and
bounds in the past several years and for many is now the
preferred method of acquiring images (versus images on
photographic lm). Digital cameras are easy to use, and
many have wonderful image quality and image size up
to 10 megapixels or more. (Pixel, by the way, is short for
picture element, the basic unit from which a video or
computer picture is made. e more pixels, the higher
the resolution of
the picture.)
Photo digital planimetry
software (PDPS) is now
available and can be
used to perform accurate measurements on
digital photographs.
PDPS mapping of
wounds or lesions is
performed on a computer using a mouse or
touch screen monitor, a
notebook tablet with
pen or USB tablet with
pen. Images of the
lesions are captured
with a digital camera
without regard to distance (as close as possible provides better
images and measurements). Parameters
include length, width,
area, circumference and
depth (added) to calculate volume (Fig. 3).

Reports can be generated for the residents chart (electronic or paper) and can also
be sent to referral sources. ese same reports might be needed for insurance
companies and Medicare for reimbursement purposes. Best of all, unlike tracings,
the data can be veried by others because the original picture is always available
for review. PDPS has been shown to have intra-rater reliability of 98.3 percent, or
less than a 1.7 percent error rate.

Fig. 2- Pictures of wounds can be stored and shown as a series of images, showing
changes in the size of the wound over time.

Fig. 3- Photo digital planimetry software shines when it comes to oddly shaped wounds. Above, an image of oddly
shaped wound (right) and the measured wound using PDPS (left).

References
1. Sheehan P, Jones P, Caselli A, Giurini J, Veves A. Percent change in wound area of diabetic foot ulcers over a
4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003
Jun;26(6):1879-82.
2. Margolis DJ, Allen-Taylor L, Hostad O, Berlin JA. e accuracy of venous leg ulcer prognostic models in a
wound care system. Wound Repair and Regeneration. 2004 Mar-Apr; 12(2):163-8
3. Van Rijswijk L, Polansky M. Predictors of time to healing deep pressure ulcers. Ostomy Wound Management.
1994 Oct;40(8):40-2, 44, 46-8 passim.
4. Alvarez OM, Markowitz L, Booker J, Rogers S, Patel M, Eectiveness of a four-layer compression bandage* and
the modied unnas boot for the treatment of lower leg ulcers in ambulatory patients with chronic venous
disease: a crossover study involving 80 patients. Abstract presented at the 18th Annual Symposium on
Advanced Wound Care. San Diego, Calif; 2005.
5. Wendelken M, Alvarez O, Markowitz L, Comfort C, Waltrous L. Key insights on mapping wounds with
ultrasound. Podiatry Today. 2006;19(7):70-74.
6. Alvarez O, Wendelken M, Markowitz L, Comfort C, Waltrose L. Wounds measured from digital photographs
using photo-digital planimetry software: validation and rater reliability. Oral abstract presented at the 19th
Annual Symposium on Advanced Wound Care. San Antonio, Texas; 2006.

An attorneys view on photographic

wound documentation
Attorneys often disagree when advising longterm care facilities regarding the use of photos for wound documentation. However,
there are times when photographic wound
documentation can be very useful to a facility. Photos can be helpful in documenting the
exact measurements of wounds present on
admission. A long-term care facility can
precisely identify the number, extent and
location of the wounds that a resident presents with at admission. e progress of those
wounds can also be well documented with
photos. e facility's wound documentation
policies and procedures must be very specic
regarding the appropriate times for photographic documentation. A facility can place
itself at increased legal risk without appropriate policies and procedures related to photographic evidence. Consult your legal counsel
prior to implementing a photographic policy
for wounds.
-Janet K. Feldkamp RN, BSN, LNHA, JD

Fig. 4- Above is a sample of a foot wound over the dorsal aspect of the toes. In comparison to traditional
measurements, PDPS provides a clear visual indicator that allows a clinician to calculate the wounds exact
surface regardless of shape.

30

HEALTHY SKIN

Improving Quality of Care Based on CMS Guidelines

31