Wound Assessment:

clinical and instrumental

Marco Romanelli, MD PhD Marco Romanelli, MD PhD
Wound Healing Research Unit
Department of Dermatology
University of Pisa
Objectives
To review the context and components of
wound assessment
To relate wound assessment to the science
of wound healing
To review current approaches to wound
measurement
Purpose of Assessment
Initial definition/diagnosis
Monitoring the effect of treatment
Monitoring for infection Monitoring for infection
Prediction of outcome
Clinical decision support
Re-imbursement
The Context of Wound Assessment
Wound assessment
occurs in the context
of a global
assessment of the assessment of the
patient
Takes into account
the TIME principles
of wound bed
preparation Wound Assessment
TIME Principles of Wound Bed Preparation
Tissue non
viable or
deficient
Infection or
inflammation
Edge of Wound
non advancing or
undermined
Moisture
imbalance
Defective matrix
and cell debris
High bacterial
counts or
prolonged
inflammation
Desiccation or
excess fluid
Non-migrating
keratinocytes. Non-
responsive wound
cells inflammation cells
Debridement Antimicrobials Dressings
Compression
Biological Agents
Adjunct Therapies
Debridement
Restore
wound base
and ECM
proteins
Low bacterial
counts and
controlled
inflammation
Restore cell
migration,
maceration
avoided
Stimulate
keratinocyte
migration
Integrating Science, Assessment and
Treatment
Chronic Wound Assessment
Rationale
To assess healing
To assess the needs of a
Questions
How can these be
achieved?
To assess the needs of a
given wound
To control the cellular /
molecular parameters
that are ideal for healing
How can we monitor
the process?
Wound Measurement
Wound Biochemical
Assessing wound healing
WA
Wound
Documentation
Predicting
Healing
Wound
Appearance
Biochemical
factors
Patient
factors
Why, When, What?
Why measure?
Diagnostic purpose
Prognostic significance
When to measure?
Clinical practice
Research purpose Prognostic significance
Therapeutic control
Objective assessment
Patient compliance
Skin accessible
Research purpose
Defined schedule
What to measure?
Wound bed
Surrounding skin
Which measurement?
Knowledge of device technical aspects
Basic knowledge of biological - physical
aspects to be evaluated
Current Practice
How do you measure wounds?
How accurate are these measurements?
How do you use this information? How do you use this information?
Measurements on wound bed
Simple
Accessible
Non - invasive
Reliable Reliable
Valid
Easy to use in the clinical setting
Reproducible
Cost effective
How would you assess the surface area of
these wounds ?
Basic wound measurement
diameter
length
width width
depth
area
volume
total time to heal
healing rate
HEALING RATE TO PREDICT
COMPLETE CLOSURE
1-5
Healing rate during first 4 weeks of treatment can
be used to predict healing
Rapid identification of patients who are unlikely Rapid identification of patients who are unlikely
to respond to conventional care will allow for
earlier interventions with alternative therapies
1. Margolis DJ et al. Diabetes Care. 1999;22:692-695.
2. Pecoraro RE et al. Diabetes. 1991;40:1305-1313.
3. Kantor J et al. Arch Dermatol. 1998;134:1571-1574.
4. Sabolinski M, Falanga V. J Invest Dermatol 1999; 112:786.
5. Falanga V, Sabolinski ML. Wounds 2000; 12:42A-46A
EDGE EFFECT: MEASURING THE HEALING RATE
Conclusions from two prospective randomized studies
Initial healing rates (at 4 weeks) predict
overall healing rates
at 12 weeks for diabetic foot ulcers (n=96)
at 24 weeks for venous leg ulcers (n=136) at 24 weeks for venous leg ulcers (n=136)
Initial healing rates of > 0.1 cm/wk correlate
with healing
Overall, a healing rate of > 0.075 cm/week
is approximately 80% sensitive and specific
Frequency of assessment
Too frequent assessment may lead to
inappropriate changes in treatment plans
Infrequent assessments may miss significant Infrequent assessments may miss significant
deterioration
Most authors support formal assessment every
2 4 weeks
Wound measurement
Basic
Intermediate Intermediate
Advanced
Wound area
two-dimensional measure B
acetate tracing metric grid B
digital wound image + planimetry I digital wound image + planimetry I
digitizing tablet I
stereophotogrammetry (3D) A
computed tomography, ultrasonography A
Wound area approximations
(Diameter product approximations)
Rectangular Area
A = l x w
Overestimates true area Overestimates true area
by 44% (p<0.001)
Elliptical Area
A = l x w x /4
Overestimates true area
by 13% (p<0.001)
Wound circumference
circumference is directly related
to both volume & area
% area reduction has been shown
to be a valid outcome measure on
its own
van-Rijswijk, Polansky (1994), Phillips et al 2000 VLU, Kantor & Margolis (2000)
Wound planimetry
Is the precise measurement of the
area contained within the wound
margin tracing or the traced margin tracing or the traced
outline of a digital image of the
wound
Acetate tracing with square
counting
More accurate than
ruler method
Permanent record
generated generated
Problem estimating
partial squares
Varies by a mean of
+O.72 cm
2
for
wounds up to 10 cm
2
Precise area measurement is
a 2 stage process
Determination of
wound margin
*
Determination of Determination of
surface area
*greatest source of error
(Ramirez et al 1969, Bohannon & Pfaller
1983, Lucas 2002)
Contact tracing
Patient positioning
Margin error
Irregular wounds
Approximations of surface area
Irregular wounds
Body curvature
Limb tapering
Square counting
Accuracy
Evidence that planimetry more
accurate for
surface area measurement
Cutler et al 1993,
Oien 2002
Richard et al 2000
Plassman & Peters 2001
Digital photography with
computerized planimetry
Comparison of
manual and
computerized
techniques to assess techniques to assess
wound size.
Reliable and
accurate
Provides digital
record
Ostomy /Wound Management
2002;48(10):46-53.
Acetate tracing with mechanical
planimetry
Reliable and
accurate
Requires more
skill skill
Provides
permanent record
Most commonly
used for studies
More costly
D. Keast et al.
Volume measurement
common use of space filling materials
dental impression material SD 10%
normal saline with film dressing SD 15% normal saline with film dressing SD 15%
hidrogel or hidrocolloid paste SD 12%
structured light techniques SD 5%
stereophotography
difficulties with tunneling and undermining
Plassman, Melhuish, Harding 1994
Wound depth/volume
Depth measurement unreliable in deep
irregular shaped wounds
(Thomas & Wysocki 1990, Harding 1994), Melhuish, Plassman, Harding (1994) (Thomas & Wysocki 1990, Harding 1994), Melhuish, Plassman, Harding (1994)
Depth measurement less reliable than
volume and area
(Schubert & Zander 1996)
The Visitrak* system
A reliable, valid method
of determining wound
surface area
Ability to track % change Ability to track % change
Easy to use in everyday
clinical setting
Can be integrated into
usual care
*Smith & Nephew
Wound tracing
Separation of backing
Bedside digitizing
Accuracy
Internal test results
25 persons 10 traces each of 5 templates of
known area known area
Tracings at different speeds
Area accuracy = 98.6%
Accuracy actually improved with increased
trace speed
D. Keast et al.
3D wound analysis
3D wound analysis
Computerized planimetry
Micro PC
Tablet PC
Laptops
Regular PC
New Macs
Mouse
THE FUTURE
Mouse
Touch Pad
Touch Screen
USB Tablet
Trackball Mouse
ARANZ Medical ARANZ Medical Silhouette Silhouette
Solution for wound imaging,
measurement and documentation
Measures area, depth, volume
Allows structure entry of wound
assessment notes
Efficient Efficient
Repeatable
Portable
Easy to use
Non-contact
Data accessible over the web
Integrates with Health Information
Systems
SilhouetteMobile in
clinical use
Conclusions - 1
Physical measurements are essential in
wound healing:
To assess tissue repair in acute and chronic To assess tissue repair in acute and chronic
wounds
To assess the needs of a given wound
The noninvasive nature of available
techniques allows repeated assessment
Conclusions - 2
Wound measurement is complex and is a
skill which requires appropriate instruction,
supervision and practice supervision and practice
Area reduction is more reliable for
predicting wound closure than other wound
dimensions
Acknowledgement
Valentina Dini, MD
Francesca Salibra, MD
Sabrina Barbanera, MD
MariaStefania Bertone, NT
Cinzia Brilli, RN
Alfredina Orsetti, RN
Susanna Zingoni, RN
Graziana Battaglia, BA