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Hand burns surface area: A rule of thumb

Article  in  Burns: journal of the International Society for Burn Injuries · March 2018
DOI: 10.1016/j.burns.2018.02.011

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 burns 44 (2018) 1346 –1351

Available online at www.sciencedirect.com

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Hand burns surface area: A rule of thumb

Dallan Dargan * , Anirban Mandal, Kayvan Shokrollahi

Mersey Burns Centre, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom

article info abstract

Article history: Introduction: Rapid estimation of acute hand burns is important for communication,
Accepted 9 February 2018 standardisation of assessment, rehabilitation and research. Use of an individual’s own
thumbprint area as a fraction of their total hand surface area was evaluated to assess
potential utility in hand burn evaluation.
Materials and methods: Ten health professionals used an ink-covered dominant thumb pulp to
Keywords: cover the surfaces of their own non-dominant hand using the contralateral thumb.
Hand Thumbprints were assessed on the web spaces, sides of digits and dorsum and palm beyond
Burns the distal wrist crease. Hand surface area was estimated using the Banerjee and Sen method,
Body surface area and thumbprint ellipse area calculated to assess correlation.
Thumb Results: Mean estimated total hand surface area was 390.0 cm2  SD 51.5 (328.3–469.0), mean
Hand injuries thumbprint ellipse area was 5.5cm2 SD 1.3 (3.7–8.4), and mean estimated print number was
73.5SD 11.0 (range 53.1–87.8, 95% CI 6.8). The mean observed number of thumbprints on one
hand was 80.1SD 5.9 (range 70.0–88.0, 95% CI 3.7), x2 =0.009.
The combined mean of digital prints was 42, comprising a mean of two prints each on volar,
dorsal, radial and ulnar digit surfaces, except volar middle and ring (3 prints each). Palmar
prints were 15 (11–19), dorsal 15 (11–19), ulnar palm border 3, first web space 2, and second,
third and fourth web spaces one each.
Using the surface of the palm alone, excluding digits, as 0.5% of total body surface area, the
area of one thumbprint was approximated as 1/30th of 1%.
Conclusions: We have demonstrated how thumbprint area serves as a simple method for
evaluating hand burn surface area.
© 2018 Elsevier Ltd and ISBI. All rights reserved.

In clinical practice, volar surface of the palm and digits

1. Introduction
Burns to the hand are common, vary in size, depth and
complexity, and may result in functional deficit despite optimal
treatment. At present, there is no standardised method for
assessing the surface area of a burn to the hand. The hand burn
severity score [1] has been proposed to predict the necessity for
surgery based on burn depth within three distinct zones of the
hand, however the size of the hand burn is not quantified.
combined is often used when completing the Lund and
Browder chart [2] and using the rule of nines [3] to estimate
1% of total body surface area (TBSA) as is widely taught as such
1
at Advanced Trauma and Life Support [4] and Emergency
TM
Management of Severe Burns [5] courses. A systematic
analysis of hand surface area trials showed that volar hand
surface area was 0.87%, and palm surface area 0.5% of total
body surface area, respectively [6]. Total hand surface area has
been estimated as 2.4% of total body surface area (TBSA) [7].

* Corresponding author. Present address: Mersey Burns Centre, Whiston Hospital, Warrington Road, Prescot, Merseyside L35 5DR, United
Kingdom.
E-mail address: dallan.dargan@sthk.nhs.uk (D. Dargan).
https://doi.org/10.1016/j.burns.2018.02.011
0305-4179/© 2018 Elsevier Ltd and ISBI. All rights reserved.
 burns 44 (2018) 1346 –1351
The Du Bois and Du Bois formula for estimating hand
surface area [8] (hand surface area=2.2hand lengthhand
circumference) was derived from 9 participants in 1916. Hand
surface area may also be estimated according to the formula
described by Banerjee and Sen [9] (hand surface area=2.432-
hand lengthhand circumference) derived from 15 Indian
participants, which was associated with the lowest error rates
when compared to direct measurement using alginate in
65 Korean participants [7]. The Banerjee and Sen formula
correlated more closely than that of Du Bois and Du Bois [8], or
Mignano and Konz [10], or the United States Environmental
Protection Agency [11].
This study was performed to form an estimate of the mean
number of thumbprints in one hand in total, on each of the
various surfaces of the hand, and assess for a correlation between
the estimated and observed number of prints based on
thumbprint area and estimated hand area. The TBSA represented
by one thumbprint was sought, and an estimation of total hand
surface area using the thumbprint method was calculated.
2. Methods
Ten clinical health professionals familiar with estimating burn
surface area, comprising doctors, nurses, hand therapists and
physiotherapists from the burn centre in our institution, were
asked to assess the number of thumbprints that could be
placed on their non-dominant hand.
Participants were asked to cover the surface of one hand
with thumbprints from their contralateral thumb pulp,
without overlapping. The entire surface area distal to the
distal wrist crease was included. An inkpad was used to create
1
the thumbprints, and Skintact flexible rulers 15cm long
(Leonard Lang, Innsbruck, Austria) were used to measure hand
length and hand circumference (Fig. 1a).
Hand length was measured as the distance from the distal
wrist crease to the tip of the middle finger. Hand circumference
(metacarpophalangeal joint width) was measured as the
maximum width of distal metacarpals on the volar aspect of
the palm. Thumbprint width and length were measured
directly on the inked dominant thumb pulp. All measurements
were made to the nearest millimetre.
The thumbprint was modelled as an ellipse. Elliptical area
was calculated according to the formula: pab where a
represents the semi-major axis and b the semi-minor axis.
The surfaces of the hand were divided into five categories to
facilitate comparison: digits, web spaces, palm, dorsum and
ulnar border. Digits were further subdivided into their
respective surfaces: volar, dorsal, radial and ulnar, and
fingernails were excluded.
The mean total number of prints was used to derive the
hand surface area represented by one thumbprint, and the
relative areas of each of the five categories estimated as a
percentage of total hand surface area. An estimate of total
hand surface area was made using the formula by Banerjee
and Sen [9], for comparison, and the chi-squared test was used
to compare the observed printed area from thumbprints with
the formula estimate.
For all estimates of surface area, the hand was assumed to
be in line with the forearm, and digits adducted. Volar
1347
surface area (VSA) included the palm and the volar surfaces
of all five digits, and was defined by the distal palmar crease
proximally. Palm surface area (PSA) was defined as the area
between the distal wrist crease and the palmodigital creases.
Total hand surface area (THSA) was defined as the entire
surface of the hand distal to the level of the distal wrist
crease, including volar, dorsal, radial and ulnar aspects of the
hand and digits.
No power calculation was performed due to absence of
similar trials examining this subject. Normally distributed
discrete variables were presented as mean standard devia-
tion (SD), and range. 95% confidence intervals (CI) were
presented for the observed and expected numbers of prints,
and means compared using the chi-squared test, and
1 1
significance set at p<0.05. Microsoft Excel (Microsoft
Corporation, Redmond, WA, USA) was used for statistical
analysis.
3. Results
Four male and 6 female participants agreed to participate,
9 of whom were right-handed. An example of the technique
is shown in Fig. 1a and b. Hand measurements are provided
in Table 1. The mean observed number of prints on one hand
was 80.1SD 5.9 (range 70.0–88.0, 95% CI 3.7). The mean
number of prints observed in each area is provided in Table 2,
and the rounded totals represented diagrammatically in
Fig. 2. The combined means of the observed totals for each
area was 80.7 prints. The sum of the rounded mean totals for
each area was 80, including a second print at the first web
space. The mean observed number of prints differed
significantly from the expected 73.5 SD 11.0 (range 53.1–
87.8, 95% CI 6.8) with x2 =0.009, but both lie within the 95%
confidence intervals.
Both the Banerjee and Sen [9], and original Dubois and
Dubois [8] formulae for hand surface area have been cited as
using the lower posterior border of the radius to the tip of the
‘second’ finger to determine hand length [7], as opposed to the
distal wrist crease in the current study. Hand length is the
cause of the majority of variation in hand surface area
estimation [7]. The distal wrist crease is 13.5mm from the
radiocarpal joint [12]. To control for this, an additional
calculation was performed adding 13.5mm to each hand
length measurement. The recalculated expected number of
prints controlling for hand length was 79.0SD 11.8 (range
56.8–94.4), which was notably similar to the observed,
demonstrating no significant difference on chi-squared
p=0.11 (Table 1). As can be seen in Fig. 1a, the prints did
occasionally cross the distal wrist crease.
Using the estimate of 0.5% for palmar surface area, and as
the palm contains 15 prints, one thumbprint equals 1/15th of
0.5%, which is 0.0333% recurring, or 1/30th of 1% of TBSA
(Table 2). The total surface area of the hand calculated as
80 thumbprints, in this cohort of ten participants, would be
2.666% recurring (800.0333%). As the volar surface area
contains 26 prints including digits, this equates to 0.87%
TBSA (26 0.0333%), which incidentally is the exact figure
quoted by meta-analysis for the volar surface area of the
hand [6].
1348 burns 44 (2018) 1346 –1351

Fig. 1 – a and b. An example of the method for estimating hand surface area. This hand had a total of 70 prints, which was below
the average of 80 prints, due to the large gaps between the thumbprints.

3.1. Summary
4. Discussion
Palm=0.5% TBSA=15 prints
Volar hand=0.87% TBSA=26 prints The size of a burn to the hand is undoubtedly one of the
Whole hand=2.66% TBSA=80 prints many factors influencing the severity and prognosis of the
1 thumbprint=0.0333% or 1/30th of 1% TBSA=1T. injury, but no recognised system for accurately quantifying it
 burns 44 (2018) 1346 –1351 1349

Table 1 – Hand measurements and observed and expected number of prints.

Parameters assessed MeanSD (range)
Age (years) 36 7.6 (26–50)
Hand length (cm) 18.2 1.2 (20.3–16.7)
Hand circumference (cm) 8.7 0.7 (7.5–9.5)
Inked thumb pulp area (cm2) 5.5 1.3 (8.4–3.7)
Mean observed total number of prints 80.1 5.9 (70.0–88.0, 95% CI 3.7)
Mean volar prints (palm & digits) 26.0 3.1 (22.0–31.0)
Mean palm:volar surface prints ratio 0.6 0.0 (0.5–0.6)
Estimated volar surface area (mean of thumb pulp area total volar prints) (cm2) 140.1 29.7 (93.5–185.7)
Estimated total hand surface area (cm2) 390.0 51.5 (328.3–469.0)
Estimated number of prints 73.5 11.0 (53.1–87.8, 95% CI 6.8)
Observed/expected number of prints (x2) p =0.009

Estimates with hand length +1.35 cm

Hand length +1.35 cm (cm)a 19.5 1.2 (18.1–21.6)
Estimated total hand surface area (cm2)a 418.8 53.5 (352.9–500.2)
Estimated number of printsa 79.0 11.8 (56.8–94.4)
Observed/expected number of prints (x2)a p =0.107

Abbreviations: SD — standard deviation, cm — centimetres, CI — confidence intervals, x2 — chi-squared test.

a
Results following addition of 1.35 cm to represent the distance from the distal palmar crease to the radiocarpal joint.

Fig. 2 – Diagram of distribution of the 80 thumbprints on the surfaces of the hand and digits.

exists. The area of full and partial thickness burn, or other
assessments of burn depth, as measured in thumbprints,
may be evaluated in a standardised manner. The surface
area of traumatic skin loss, dermatitis, cellulitis and localised
swelling of the hand could also potentially be quantified
using this method. A useful descriptor for surface area of
hand burns is the number of ‘T’s, or thumbprint equivalents,
according to the simple equation:
T0.0333=% surface area
and hence a burn equivalent to 10 thumbprints can be
described as either a 10T burn or 0.33% TBSA.
Paediatric hands have a volar surface area of approximately
1.36% TBSA, and palmar surface area of 0.63% [6], and may
have different ratios of thumbprint size to hand surface area,
however the thumbprint concept may be more pertinent in
this group to control for the wider variation in hand size.
4.1. Accuracy of results compared with other studies
The mean total hand surface area is lower in this sample
(390.0cm2) than when estimated using alginate (males 448cm2,
females 392cm2) [7], but similar after controlling for the 1.35cm
from the distal palmar crease to the radiocarpal joint
(418.8cm2). however the estimated volar surface area corre-
sponds to that calculated using two-dimensional projection
(males 139.9cm2, females 114.7cm2) [13].
Estimates of the percentage of TBSA comprised by the volar
surface of the hand vary by up to 30%, including 0.7% [14] and
1.2% of TBSA [7]. Accounting for up to 30% variation in the use
of 1/30th (0.333%) to represent the area of one thumbprint,
results in a range of 0.023%–0.043%.
The distal wrist crease was used as the proximal extent of
the hand as it is the only wrist crease of sufficient consistency
1350 burns 44 (2018) 1346 –1351

Table 2 – Number of thumbprints in each area of the hand.

Mean number of Range Standard Mean number of thumbprints rounded to %TBSA 0.0333% per print
thumbprints deviation nearest whole number (1/30th of 1%)
Volar surface of 26.0 22.0–31.0 3.2 26 0.87%
the hand
Palm (excluding 14.5 11.0–19.0 2.8 15 0.50%
digits)
Dorsum 15.3 11.0–19.0 2.9 15 0.50%
(excluding
digits)
Ulnar border of 2.5 2.0–3.0 0.5 3 0.10%
palm

Web spaces
First 1.1 1.0–1.5 0.2 2a 0.03%
Second 1.0 1.0–1.0 0.0 1 0.03%
Third 1.0 1.0–1.0 0.0 1 0.03%
Fourth 1.0 1.0–1.0 0.0 1 0.03%

Thumb
Volar 2.0 2.0–2.0 0.0 2 0.07%
Dorsal 2.0 1.5–2.5 0.2 2 0.07%
Radial 2.0 2.0–2.0 0.0 2 0.07%
Ulnar 2.0 2.0–2.0 0.0 2 0.07%

Index
Volar 2.4 2.0–3.0 0.4 2 0.07%
Dorsal 2.3 2.0–3.0 0.4 2 0.07%
Radial 2.3 2.0–3.0 0.4 2 0.07%
Ulnar 2.2 2.0–3.0 0.3 2 0.07%

Middle
Volar 2.7 2.0–3.0 0.4 3 0.10%
Dorsal 2.4 2.0–3.0 0.3 2 0.07%
Radial 2.4 2.0–3.0 0.5 2 0.07%
Ulnar 2.4 2.0–3.0 0.5 2 0.07%

Ring
Volar 2.5 2.0–3.0 0.5 3 0.10%
Dorsal 2.3 2.0–3.0 0.4 2 0.07%
Radial 2.2 2.0–3.0 0.4 2 0.07%
Ulnar 2.2 2.0–3.0 0.4 2 0.07%

Little
Volar 2.0 2.0–2.0 0.0 2 0.07%
Dorsal 2.0 2.0–2.0 0.0 2 0.07%
Radial 2.0 2.0–2.0 0.0 2 0.07%
Ulnar 2.0 1.5–2.0 0.2 2 0.07%

Totals 80.7b – – 80 prints 2.66%

a
The first web space is larger and was often underestimated by participants. Therefore, the first web space was represented as a total of two prints,
one volar and one dorsal.
b
This differs slightly from the value of 80.1 prints in Table 1 due to variation in totals for individual areas.

to be considered a landmark [15,16], it is a visible surface 4.2. Limitations

landmark as opposed to the bony landmarks, and marks the
proximal junction of the glabrous skin of the palm [17]. The
inter-styloid line of the distal radius and ulna has been
suggested as the proximal extent, [6] however a variety of
measures have been used in the literature.
The relative area of the thumb pulp which was inked differed
slightly between participants, as did the size of thumbprint on
different concave and convex surfaces of the hand. The thumb
pulp is wider than the lateral aspects of the digits, and this
 burns 44 (2018) 1346 –1351
method may overestimate the contribution of the digits to total
hand area relative to the palm and dorsum. The small
discrepancy in area can be appreciated if the volar digits are
placed flat and adducted on the contralateral palm. Fingernails
and fingertips were excluded, which would equate to approxi-
mately half of a thumbprint each. Body shape, body mass index
and ethnicity were not accounted for in this study, although
they have been shown to influence the ratio of hand to total
body surface area ratios [6].
4.3. Utility of estimating hand burn area
Hand burns are regarded as complex burns and “should
prompt a discussion with a Consultant in a specialised burn
care service, and consideration given to referral”, or be referred
“where the referrer feels that greater multi-disciplinary team
expertise is required” according to the UK National Burns Care
Standards [18]. Accurate evaluation of the size of hand burns,
and of all burns less than 1% TBSA, is an essential step on the
path to optimising outcomes through ongoing research and
evaluation of service provision.
At present, many referrals to specialist centres involve a
telephone conversation, and a standardised system of evalu-
ation would facilitate triage of such a frequently-burnt area. In
clinical scenarios, clinicians may use their own dominant
thumb, on their own non-dominant hand, to estimate the burn
size, thereby avoiding pain for the patient. Combining size of
burn estimation with zone of hand burn [1] may could lead to
early identification of burns requiring surgery, or at contrac-
ture risk. The potential for use of technology, including camera
phones [19] and telemedicine as recommended by the
National Network for Burn Care [20] for evaluation of burns
to facilitate referral, in addition to smartphone apps such as
MerseyBurns© [21], may play a role in streamlining referrals in
the near future, potentially via establishing local standard
operating protocols [22] to ensure best use of the multi-
disciplinary team, and best outcomes.
Until now, it has not been possible to differentiate between
burns of the hand– these injuries are often arbitrarily estimated
as, for instance: 0.5% or 0.1% or <1%. We have now developed a
much more accurate, sensitive, standardised and reproducible
tool to evaluate and document burns of the hand in adults.
5. Conclusions
Thumbprint estimation provides a rapid, objective, simple,
standardised and accessible method for quantifying hand
burn surface area. Each hand is on average 80 thumb prints
including volar, dorsal, radial and ulnar surfaces, and each
thumbprint 0.0333% (1/30th of 1% TBSA). A simple descriptor
that can be used is the number of 'T's for each burn such that a
10T burn is a 10 thumb-print surface area burn, equivalent to
0.33% TBSA.
Conflict of interest
None.
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1351
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