title: Photographic assessment of burn size and depth: reliability and validity.
abstract: OBJECTIVE
  The aim of this study was to examine the reliability and validity of using photographs of burns to assess both burn size and depth.
  
  
  METHODS
  Fifty randomly selected photographs taken on day 0-1 post burn were assessed by seven burn experts and eight referring physicians. Inter-rater reliability in both groups (experts vs. referrers) was calculated. The validity of burn size assessment was calculated using live assessment as the gold standard, and of burn depth using clinical assessment in combination with laser Doppler imaging as the gold standard. The validity of the photographically-assessed indication for surgery was calculated using laser Doppler imaging and actual treatment as the gold standard. Finally, agreement in referral indication was calculated.
  
  
  RESULTS
  Using photographs, burn size could be assessed reliably and validly by experts (ICCs of 0.83 and 0.87), but not by referrers (ICCs of 0.68 and 0.78). Photographic assessment of burn depth was neither reliable nor valid, with ICCs respectively of 0.38 and 0.28 for experts and 0.24 and 0.13 for referrers. The indication for surgery could also not be assessed validly. Agreement between assessors regarding referral indication was low.
  
  
  CONCLUSIONS
  Burn size, but not burn depth, can be assessed reliably and validly by experts using photographs of the burn wound. We recommend exploring other forms of telemedicine, like live interactive video, to investigate whether this leads to an improved burn depth assessment where clinical assessment is not possible.
  
  
  BACKGROUND
  There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to the manuscript or its content.
authors.affiliation: MD, Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University Medical Centre, Amsterdam, the Netherlands; Department of Plastic and Reco.
authors.forename: M J
authors.initials: MJ
authors.lastname: Hop
authors.affiliation: MD, PhD, Department of Plastic and Reconstructive Surgery, Medical Centre Leeuwarden, the Netherlands.
authors.forename: C M
authors.initials: CM
authors.lastname: Moues
authors.affiliation: BSc, Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, the Netherlands.
authors.forename: K
authors.initials: K
authors.lastname: Bogomolova
authors.affiliation: PhD, Association of Dutch Burn Centres, Martini Hospital, Groningen, the Netherlands.
authors.forename: M K
authors.initials: MK
authors.lastname: Nieuwenhuis
authors.affiliation: MD, Burn Centre, Maastad Hospital, Rotterdam, the Netherlands.
authors.forename: I M M H
authors.initials: IM
authors.lastname: Oen
authors.affiliation: PhD, Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University Medical Centre, Amsterdam, the Netherlands; Association of Dutch Burn Centres, Red Cross Hospital, Beverwijk, the Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Middelkoop
authors.affiliation: MD, PhD, Department of Surgery/Burn Centre, Red Cross Hospital, Beverwikj, the Netherlands; Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
authors.forename: R S
authors.initials: RS
authors.lastname: Breederveld
authors.affiliation: PhD, Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, the Netherlands.
authors.forename: M E
authors.initials: ME
authors.lastname: van Baar
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002056:Burns / Q000473:pathology*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D017078:Laser-Doppler Flowmetry; D008297:Male; D008875:Middle Aged; D010781:Photography; D015203:Reproducibility of Results; D017216:Telemedicine