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Three Part Question

In [assessment of burns] is [the hand method] an accurate method for [estimation of burn surface area]

Clinical Scenario

A 2 year old boy attends the Emergency Department after pulling a pot of tea over himself. Using the hand method (child's palm including fingers equals 1%) you estimate he has a 12% burn. Using a Lund-Browder chart results in estimation of a 9% burn. You wonder how accurate the hand method is.

Search Strategy

Medline 1966-10/07 using the OVID interface
[Hand surface area.mp] LIMIT to human and English

Search Outcome

9 papers were found of which 4 were relevant
A bibliography search of these papers, + Google and EMJ online searches yielded another 5 papers.
These 9 papers are included in the table below

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nagel TR, Schunk JE 1997 USA	91 children. Age 1-13	Prospective cohort study	Used photocopy of hand to calculate surface area. Entire palmar surface of child's hand approximates 1%. Palm approximates 0.5%	Mean % of TBSA of hand including fingers was 0.94%	Not randomised sample
Jose RM, Roy DK, Wright PK, Erdmann M 2006 UK	120 doctors and nurses from one hospital 40 in each ethnic group	Prospective cohort study	Tracing hand outline and calculating surface area. Split into 3 ethnic groups. Hand surface area 0.67-1.1% Caucasian, 0.78-1.1% Asian, 0.82-1.4% Oriental	No significant difference between 3 ethnic groups	Representative sample? Only small number of ethnic groups were represented (all Oriental group were Filipino)
Tikuisis P, Meunier P, Jubenville CE 2001 Canada	12 men and 12 women sampled from population of 395 men and 246 women	Prospective cohort study	Three-dimensional body scan. Hand surface area calculated in small sample of subjects	Higher SA/vol ratios in men than women. % BSA not given	Results difficult to apply clinically without % BSA Small numbers
Sheridan RL, Petras L, Basha G 1995 USA	69 patients (60 children, 9 adults)	Prospective cohort study	Planimetry to measure palmar surface area	Surface area of palm averaged 0.52% TBSA, or 0.85% including fingers. Palm alone was more consistent template	Only small number of adults
Perry RJ, Moore CA 1996 UK	20 adults (from medical school) 10 children (from hospital)	Prospective cohort study	Heights and weights recorded. TBSA calculated. Hand measured and SA calculated by computer program	Whole hand equates to 0.79% (0.77% adult, 0.82% children)	Small numbers Different sample groups for adults and children
Rossiter ND, Chapman P, Haywood IA 1996 UK	70 adult volunteers (patients and staff) 36 male and 34 female	Prospective cohort study	Weight, height and body surface area calculated. Hand outlined on graph paper and squares enclosed in outline counted	Palm 0.5% BSA in male, 0.4% in female. Palm + fingers 0.81% in male, 0.67% in female	Not randomised sample Accuracy of graph paper?
Amirsheybani HR, Crecelius GM 2001 USA	800 volunteers aged 2 to 89	Prospective cohort study	Bilateral hand tracings taken then calculated as % BSA. In male, female, adult and child area of dominant hand was 0.82+/-0.08%. SA maximal at age 3	In adults palm including fingers is 0.78%, number slightly higher in children (up to 0.87%)	Not randomised sample
Berry MG, Evison D, Roberts AH 2001 UK	30 healthy volunteers 15 male, 15 female Age 19-49	Prospective cohort study	Dominant hand surface area measured by digital scan and software analysis. Mean hand surface area was 0.83% in healthy volunteers, 0.71% in overweight and 0.70% in obese	Mean hand surface area diminished significantly as BMI increased (both sexes but more pronounced in women) For BMI>31 palm + fingers =0.64%	Small numbers
Lee JY, Choi JW 2007 USA	34 Korean males (20-60 years) 31 Korean females (20-63 years)	Prospective cohort study	Hand surface area and BSA measured directly using alginate	Hand as % BSA was 2.5% in male, 2.45% in female. No significant difference between sexes. 2.3% in overweight group	Measured hand as a whole rather than palmar surface, therefore difficult to apply clinically

Comment(s)

Hand estimation of burn surface area provides an easy method for assessment of burns, particularly if irregularly shaped or partially involving limbs. Lund and Browder reported the total surface area of the hand to be 2.5% with the palmar surface being 1%. However in these studies the hand surface area has been found to be less than 1% and the palm alone less than 0.5% leading to the potential overestimation of burn size and subsequent over-resuscitation with fluids. This may be compounded by other factors such as obesity and gender differences. Calculating palmar surface as 0.8% rather than 1% may give a more accurate estimate.

Clinical Bottom Line

Hand estimation is an unreliable method and can lead to overestimation of burn surface area

References

1. Nagel TR, Schunk JE Using the hand to estimate the surface area of burn in children Pediatr Emerg Care 1997 Aug;13(4):254-5
2. Jose RM, Roy DK, Wright PK, Erdmann M Hand surface area - do racial differences exist? Burns 2006 Mar;32(2):216-7
3. Tikuisis P, Meunier P, Jubenville CE Human body surface area: measurement and prediction using three dimensional body scans European Journal of Applied Physiology 2001 Aug;85(3-4):264-71
4. Sheridan RL, Petras L, Basha G Planimetry study of the percent of body surface area represented by the hand and palm J Burn Care Rehabil 1995 Nov-Dec;16(6):605-6
5. Perry RJ, Moore CA Determining the approximate area of a burn: an inconsistency investigated and re-evaluated BMJ 1996 May 25;1338
6. Rossiter ND, Chapman P, Haywood IA How big is a hand? Burns 1996 May;22(3):230-1
7. Amirsheybani HR, Crecelius GM The natural history of growth of the hand: 1.Hand area as a percentage of body surface area Plastic Reconstr Surg 2001 Mar;107(3):726-33
8. Berry MG, Evison D, Roberts AH The influence of body mass index on burn surface area estimated from the area of the hand Burns 2001 Sept;27(6):591-4
9. Lee JY, Choi JW Determination of hand surface area using alginate Journal of Physiological Anthropology 2007 June;26(4):475-83