Medical photography: principles for orthopedics
© Uzun et al.; licensee BioMed Central Ltd. 2014
Received: 10 October 2013
Accepted: 27 March 2014
Published: 5 April 2014
Medical photography is used clinically for patient evaluation, treatment decisions, and scientific documentation. Although standards for medical photography exist in many branches of medicine, we have not encountered such criteria in publications in the area of orthopedics.
This study aims to (1) assess the quality of medical images used in an orthopedic publication and (2) to propose standards for medical photography in this area.
Clinical photographs were reviewed from all issues of a journal published between the years 2008 and 2012. A quality of clinical images was developed based on the criteria published for the specialties of dermatology and cosmetic surgery. All images were reviewed on the appropriateness of background, patient preparation, and technique.
In this study, only 44.9% of clinical images in an orthopedic publication adhered to the proposed conventions.
Standards have not been established for medical photography in orthopedics as in other specialty areas. Our results suggest that photographic clinical information in orthopedic publications may be limited by inadequate presentation. We propose that formal conventions for clinical images should be established.
Medical photography is used clinically for evaluation, treatment planning, and scientific documentation. The use of clinical images enhances communication of concepts in both specialty-specific presentations and written articles. Photography was first widely used in publications particularly in the areas of dermatology and plastic and reconstructive surgeries, where the inclusion of photographic images is recognized to enhance the descriptions of diagnoses and complex procedures. In these specialties, standards for medical images have been established for publications [1–3].
Are photographic standards published for plastic surgery and dermatology appropriate for orthopedics?
What are applicable standards for clinical images?
Do recently published clinical images meet these criteria, as assessed by a survey of images in one orthopedic journal?
Material and methods
A general orthopedics and traumatology journal was selected from those indexed in PubMed and SCI-expanded. The journal is published six times yearly. From all the articles published in the last 5 years, between 2008 and 2012, we identified and analyzed 235 clinical patient photographs. Intraoperative pictures, surgical technique diagrams, pictures that were taken in emergency departments, implant and arthroscopic camera images, and radiographs or other advanced imaging illustrations were excluded. Ethical permission was taken from the journal editorial office. Each author certifies that his or her institution has approved the reporting of this report and that all investigations were conducted in conformity with ethical principles of research.
Background: The choice of background color should provide an appropriate contrast. How much of the image area is made up of the background?
Patient preparation: The extremities should be presented without clothing or accessories. There should be no visible clothing, rings, watches, or bracelets.
Image technique: The anatomic landmarks of the area being photographed should be visible in each image and should fill the photographed area. Using the anatomic landmarks, the subject being photographed should be in a reproducible standard position (e.g., images fully showing angle of movement of a joint: side view of knee in full flexion and extension—anterior and posterior views for varus-valgus). Thus, the representation of anatomic landmarks in each image was assessed.
Positioning: Patient should extend the finger being examined and place it next to tape marks that are perpendicular to the camera axis.
Framing: Place metacarpophalangeal joint at the edge of the frame. Center finger vertically (Figure 1).
Positioning: Same as that of the finger.
Framing: Center hand in frame (Figure 2).
- 3.Forearm and elbow
Positioning: Patient should extend the arm and horizontally position it above the tape marks that are perpendicular to the camera axis.
Framing: Place elbow at the edge of the frame and center forearm vertically (Figure 3).
Positioning: Patient must comfortably stand erect with arms on the sides.
Framing: Position clavicles at the top of the frame.
- 5.Knee and foot
Positioning: Patient should stand on a step stage with foot at approximately at shoulder width.
Framing: Position toes at the bottom of the frame. Center foot horizontally (Figure 4).
Inappropriate photo range
Appearance of bijou and other accessories
Inappropriate photo number
The capture of a moment in time has always been of great interest to mankind. After many unsuccessful attempts, the moment was captured by photograph in 1816 by the French inventor, Joseph Nicephore Niepce . From that date onwards, photography began to develop, and the areas of its use expanded. Photography first entered the field of medicine in 1852 when Albert Sands Southworth and Josiah Johnson Hawes recorded the first use of ether anesthesia . The analog camera was launched in the market in 1888 by Kodak (Rochester, NY, USA) [4–6]. The use of this camera was limited: it was difficult to use, images could not be viewed immediately, and printing took time and was not cost effective . After many advancements in technology, however, including the development of digital cameras, camera usage has become widespread in medicine, particularly in dermatology, plastic surgery, forensic medicine, anatomy, pathology, and orthopedics [1, 8, 9]. In plastic surgery and dermatology, photographic communication of specialty-specific information has been recognized as highly important, and the importance of standardization and quality of clinical images has been recognized [1, 3, 7, 10–16]. These specialties therefore established standards for published clinical images to maximize the information that can be communicated by these figures.
The purpose of this study was to assess the presentable quality of images used in an orthopedic publication and to propose standards for medical photography in orthopedic surgery. No published standards exist for the presentation of orthopedic clinical images. The journal selected for this study is accepted as an international general orthopedics journal and includes a wide range of orthopedic images. Only clinical photographs, except those in the emergency or operating rooms, were evaluated in this study. Separate conventions would be useful for standardizing the presentation of radiographs, arthroscopic images, and other imaging information, but these issues are beyond the scope of this study.
The applicable accepted conventions for clinical photography in dermatology and plastic surgery describe equipment, background selection, accessories, patient preparation, and photographic techniques [2, 3, 17–19]. Equipment quality is important, and it has been reported that photographs should be taken with cameras that have at least 3.2 megapixels . In this study, the camera features could not be evaluated, and it should be noted that photo quality may also be affected by the file format, such as TIFF, JPEG, or BIT.
In the evaluation of accessories, it has been reported that the most important accessory is a tripod to enable precise control of the camera angle [2, 3, 21–23]. In this study, we could not evaluate the use of a tripod, photography practices, or camera features, since the articles did not include this information.
In conclusion, this study found that clinical images in an orthopedic journal did not adhere to standards of image quality which have been previously established in the fields of dermatology and plastic surgery. Subjectively, during the review of these images, it was the opinion of the author that some images nonetheless adequately presented clinical information, but some could have been improved by adherence to the standards proposed above. In the development of the imaging criteria used in this study, an effort was made to apply only basic photographic standards appropriate for orthopedic information: background, patient preparation, and perspective technique.
Photography has become increasingly important in medicine for the communication of complex, specialty-specific clinical information. As has been established already in other specialties, in orthopedics, results should be presented using appropriate techniques (Figure 9). Standards for orthopedic images should be established to include conventions for the use of background, patient preparation, and perspective techniques. By establishing such a lingua franca, the quality of clinical images available in the literature would be improved, as would even an individual clinician's ability to compare pre- and post-treatment outcomes. The results of this study highlight the need for established standards for medical photography in orthopedics.
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