Estimation of burn surface area using the hand
Date First Published:
September 25, 2007
Last Updated:
November 16, 2007
Report by:
Helen Blackhurst, SPR Emergency Medicine (Cheltenham General Hospital)
Search checked by:
Faye Dagger, Cheltenham General Hospital
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
Search Details:
[Hand surface area.mp] LIMIT to human and English
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
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Using the hand to estimate the surface area of burn in children 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 |
| Hand surface area - do racial differences exist? 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) |
| Human body surface area: measurement and prediction using three dimensional body scans 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 |
| Planimetry study of the percent of body surface area represented by the hand and palm 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 |
| Determining the approximate area of a burn: an inconsistency investigated and re-evaluated 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 |
| How big is a hand? 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? |
| The natural history of growth of the hand: 1.Hand area as a percentage of body surface area 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 |
| The influence of body mass index on burn surface area estimated from the area of the hand 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 |
| Determination of hand surface area using alginate 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 |
Author Commentary:
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.
Bottom Line:
Hand estimation is an unreliable method and can lead to overestimation of burn surface area
References:
- Nagel TR, Schunk JE. Using the hand to estimate the surface area of burn in children
- Jose RM, Roy DK, Wright PK, Erdmann M. Hand surface area - do racial differences exist?
- Tikuisis P, Meunier P, Jubenville CE. Human body surface area: measurement and prediction using three dimensional body scans
- Sheridan RL, Petras L, Basha G. Planimetry study of the percent of body surface area represented by the hand and palm
- Perry RJ, Moore CA. Determining the approximate area of a burn: an inconsistency investigated and re-evaluated
- Rossiter ND, Chapman P, Haywood IA. How big is a hand?
- Amirsheybani HR, Crecelius GM. The natural history of growth of the hand: 1.Hand area as a percentage of body surface area
- Berry MG, Evison D, Roberts AH. The influence of body mass index on burn surface area estimated from the area of the hand
- Lee JY, Choi JW. Determination of hand surface area using alginate