Burns 26 (2000) 156±170

www.elsevier.com/locate/burns

The inter-rater reliability of estimating the size of burns from

various burn area chart drawings
Thomas L. Wachtel a,*, Charles C. Berry b, Edward E. Wachtel c, Hugh A. Frank d
a
Trauma Services, Centura Health St. Anthony Central Hospital, 4231 West 16th Avenue, Denver, CO 80204-1374, USA
b
Department of Family and Preventive Medicine, University of California, San Diego, USA
c
North Central Ohio Consortium for Mathematics and Science, The Ohio State University at Mans®eld, Ohio, USA
d
Regional Burn Treatment Center, University of California, San Diego, USA
Accepted 2 March 1999

Abstract

The accuracy and variability of burn size calculations using four Lund and Browder charts currently in clinical use and two
Rule of Nine's diagrams were evaluated. The study showed that variability in estimation increased with burn size initially,
plateaued in large burns and then decreased slightly in extensive burns. The Rule of Nine's technique often overestimates the
burn size and is more variable, but can be performed somewhat faster than the Lund and Browder method. More burn
experience leads to less variability in burn area chart drawing estimates. Irregularly shaped burns and burns on the trunk and
thighs had greater variability than less irregularly shaped burns or burns on more de®ned anatomical parts of the body. # 2000
Elsevier Science Ltd and ISBI. All rights reserved.

Keywords: Burns; Burn diagram; Burn estimation; Reliability

1. Introduction parts of the body as a percentage of the total body

Severity index classi®cations for burn injuries and
prognostic forecasts for burned patients currently rely
heavily on estimates of the proportion of body surface
area burned. In addition, the severity index may
include the depth of the thermal injury, the age and
sex of the patient, respiratory damage and the associ-
ated injuries and illnesses [1±7]. Of these categories, it
is the extent of body surface area burned expressed as
percentage of the total body surface area that is most
widely used for planning management (e.g., ¯uid
therapy, nutritional support) and predicting outcome
(e.g., morbidity and mortality) [7±9]. Moreover, this
information is used to compare data among patients
within an institution, as well as, between institutions
[6±8] and as a basis for studying cost e€ectiveness.
Estimates of the relative surface area of various
* Corresponding author.
surface area were made in 1924 by Berkow to evaluate
the extensiveness of burn lesions [10]. Lund and
Browder found that Berkow's tables were not appli-
cable to all age groups [11]. They determined the
changes in percentage of body surface of various parts
of the body that occur during the di€erent stages of
development from infancy through childhood. The
area of the head makes up a relatively large portion of
the total skin area in infants as compared with adults.
This proportion is counterbalanced in infants by the
smaller area of the thighs and legs. The proportion of
the skin on all other parts of the body is essentially
the same for all age groups. This work has been
accepted as basic since 1944 and has not been repeated
or correlated.
The most accurate method for determining percen-
tage of body surface burned reportedly is to map out
the areas of injury on Lund and Browder charts [11±
13]. If these charts are not immediately available for
an initial estimate or time is a factor at the initial

0305-4179/00/$20.00 # 2000 Elsevier Science Ltd and ISBI. All rights reserved.
PII: S 0 3 0 5 - 4 1 7 9 ( 9 9 ) 0 0 0 4 7 - 9
 T.L. Wachtel et al. / Burns 26 (2000) 156±170
Fig. 1. Artist's burn area chart drawings of ten representative burns
describing second (hatched areas) and third (solid areas) degree
burns of various areas of the body. The letters are used to code
these drawings and correspond to the nomenclature used in various
tables.
triage (e.g. at the scene of the accident), a convenient
and rapid method of estimating the percentage of the
body surface burned is the use of the Rule of Nine's
[13,14]. According to the Rule of Nine's, ®rst devised
by E.J. Palaski and C.W. Tennison [15], the body sur-
face is divided into areas representing 9% or multiples
of 9% of the total body surface area. The extent of the
burn is only rarely underestimated [16]. Over esti-
157
mation is common and frequently results in excessive
¯uid administration [17].
Although the Lund and Browder and the Rule of
Nine's burn area charts have been accepted widely as
useful guides in estimating percentage of body surface
burned, few studies have indicated the reliability with
which these estimates can be applied [18]. There is no
estimation of the accuracy or precision of these burn
area chart drawings, nor have the di€erences between
the Lund and Browder and the Rule of Nine's topo-
graphs been evaluated. The reliability of the individual
components of any severity index is vital in the com-
parative assessment of methods of treatment, morbid-
ity, mortality, and cost. Obviously errors that
systematically underestimate or overestimate the size
of the burn will bias the results of all other studies
comparing groups of patients. This study was designed
to assess the variation between observers estimating
the area burned from standard burn area chart draw-
ings made on a number of burn area charts currently
in clinical use. We have also assessed the bias intro-
duced by the burn area chart itself and examined some
other problems and uncertainties associated with the
use of burn area charts and drawings.
2. Methods
2.1. Diagrams and drawings
The burn area chart drawings (also referred to as:
drawings, burn drawings or simulations) of twenty-six
di€erent patients that had been admitted to our burn
center with burns of varying sizes, shapes and lo-
cations were given alphabetical letters A to Z. Ten
burns from this sample were randomly selected and
uniform artist's drawings were made to represent the
second and third degree burns (Shown in alphabetical
order in Fig. 1). These drawings were duplicated pre-
cisely on six di€erent forms (also referred to as: dia-
grams, charts and burn area charts; Figs. 2±7) of
which one is the original Lund and Browder chart [11]
(Fig. 5), three are modi®ed Lund and Browder charts
(Figs. 2, 4 and 6) and two are burn area charts that
were converted to represent the Rule of Nine's (Figs. 3
and 7). The resulting 60 di€erent simulations (six
di€erent forms 10 di€erent burn area chart drawings)
were used in the project. These simulations were ran-
domized using the method of latin squares and distrib-
uted to each member of the estimation team in 10
packets of six simulations each, along with general
instructions on how to complete the assigned burn size
estimations. The rationale for randomization and dis-
tributing six simulations at a time was that the estima-
tor would not receive two of the same burn area chart
drawings at any given time. The six blank original
158 T.L. Wachtel et al. / Burns 26 (2000) 156±170

Fig. 2. Modi®ed Lund and Browder Burn Area Chart used at the San Diego and Imperial County Regional Burn Treatment Center, University
of California, San Diego (UCSD). The critical areas of the head (four views) and the hands (anterior and posterior views) have been enlarged.
Modi®cations from the original Lund and Browder Method are that the hands are bigger (0.5%/hand), the anterior trunk is larger (2%), and the
thighs are smaller (1 and 1.5%/thigh).

forms (Figs. 2±7) were included in the assignment
envelope for reference each time. Each member even-
tually received all 60 burn area chart drawings to esti-
mate and return and only the drawings of the 24
estimators who completed all of the estimations,
marked the time required for each estimation and
answered the questionnaires were included for this
study.
All drawings assumed that the patient was an adult.
In each case the estimator used the system designed by
the particular form on which the burn drawing
appeared. Each rater was admonished not to make
mathematical errors and not to calculate a burn area
accurate to less than 0.25%. The estimators were
instructed to do each drawing separately comparing
the drawing to the appropriate one of the reference six
blank original forms only when the solid or hatched
areas of the drawing obscured the percentage number
of that area or a dividing line between two anatomical
regions. The raters were not allowed to compare one
drawing with another or to compare their estimates
with other estimators' ratings.
2.2. Evaluators
The estimation team (also referred to as: estimator,
 T.L. Wachtel et al. / Burns 26 (2000) 156±170 159

Fig. 3. The University of California, San Diego Burn Area Chart converted to a Rule of Nine's Diagram (UCSD-9).

rater, observer or evaluator) involved 24 di€erent vol-
unteers from our burn unit who completed the entire
project (all 60 burn area drawings, time sheets and the
questionnaires). The background of this team was:
four burn surgeons (two plastic surgeons and two gen-
eral surgeons) all with extensive burn experience, two
general surgical residents in their second post graduate
year with 2 months of burn experience, two physician
assistants with 1 year of burn experience each, eleven
burn nurses with a variety of burn experience from 1
to 7 years, one nurse with no burn experience, one
medical social worker who worked with burned
patients, two burn technicians with 2 years burn ex-
perience each, one mathematician without burn experi-
ence, and one skin bank technician pre-med student
with 1 year of burn experience. Each of these people
calculated the percent of second degree burn, the per-
cent of third degree burn and the percent of total body
surface burned for each simulation and recorded the
time that it took her or him to do each estimate. The
usual practice in our burn unit was that the resident,
attending burn surgeon or physician's assistant com-
pleted the initial burn area diagram for the patient,
but burn nurses frequently did so as well.
2.3. Analysis
The percent second degree burn, the percent third
degree burn, the percent total body surface area
burned and the time required to do the entire esti-
mation for each of the 10 drawings on each of the six
di€erent forms (a total of 60 simulations) for each of
160 T.L. Wachtel et al. / Burns 26 (2000) 156±170

Fig. 4. A Lund and Browder Chart published and distributed by the Burn Treatment Skin Bank, Phoenix, Arizona (BTSB). Their artist drew the
®gures. The anterior/posterior orientation is reversed from the other burn area charts.

the 24 estimators was recorded on a master ¯ow sheet.
The master ¯ow sheet was used as input for computer
analysis. The mean and standard deviation for each of
the burn area chart drawings for all raters were
obtained. A computer and a statistical program
(BMDP2 V) were used to make comparisons between
the burn drawings and between observers with di€er-
ent levels of burn experience. A planimeter was used
to determine the accurate percentage of each area of
burn on each drawing.
In addition, each estimator was given open-ended
written and oral questionnaires that were used to
determine the problems encountered in estimating.
Each evaluator was asked to recommend solutions for
improving the process and precision and accuracy of
estimating the burn area from the burn area chart
drawing.
 T.L. Wachtel et al. / Burns 26 (2000) 156±170 161

Fig. 5. A replication of the original Lund and Browder Chart used by the Cook County Burn Unit (CHI).

3. Results
The mean and standard deviation (partial thickness,
full thickness and total burn area) for all estimators
for each of the 60 simulations and the values deter-
mined by planimeter for each drawing are presented in
Table 1. The representative burns (Fig. 1) could be
divided into two groups. One group (drawings C, N,
R, T, U) consists of those drawings in which burns of
irregular shape covered the trunk and/or legs, while
the other (drawings A, B, E, H, Z) did not have such
irregularly shaped burns and were on more de®ned
anatomical areas. The variability for the drawings of
the ®rst group was greater than for drawings of the
latter group. The mean square for error was 24.80,
21.27, and 32.81 for partial, full and total burn re-
spectively, for irregularly shaped burns as compared to
11.46, 5.59, 16.37 for less irregularly shaped burns in
similar categories. These di€erences are statistically sig-
ni®cant.
Table 2 re¯ects the variability of estimates of each
type of burn area diagram used in this project.
Drawings on the BTSB charts show less variability
than burn drawings on the other charts for partial
thickness burn and for total burn. Both of these di€er-
ences are statistically signi®cant. When the diagrams
are compared the estimates on the UCSD diagram
more often approximated the actual burn size deter-
162 T.L. Wachtel et al. / Burns 26 (2000) 156±170

Fig. 6. National Burn Information Exchange (NBIE) burn diagram and estimate sheet. (Courtesy of Dr. Irving Feller, 200 Ingalls, Ann Arbor,
MI)

mined by the planigram (37%) followed by the CHI
(20%), NBIE (17%), and BTSB (10%). Estimates
using the Rule of Nine's diagrams (Figs. 3 and 7) were
least precise.
Table 3 compares the mean estimated burn size for
each of the 10 burn drawings using the modi®ed Lund
and Browder (UCSD & NBIE) versus the Rule of
Nine's methods (UCSD-9 & NBIE-9). The variability
of estimates for the UCSD chart was less than that for
the corresponding Rule of Nine's chart for partial
thickness burns ( p < 0.05) and for total area burned
(not signi®cant; NS) but not for full thickness burns
(NS) (Table 2). For the NBIE diagrams (Figs. 6 and 7)
the variability of estimates for the Lund and Browder
chart was smaller for partial thickness, full thickness,
and total burn than was the Rule of Nine's counter-
part (Table 2). These di€erences are each statistically
signi®cant (paired t-test, p < 0.05). The Rule of Nine's
estimates were 3% larger than their comparative esti-
mate for the same burn representation using Lund and
Browder type charts.
Table 4 lists the average time in minutes required to
estimate the size of burn for each drawing on each
type of diagram. Estimation of the burned area can be
made in a shorter time using the Rule of Nine's than it
can be done using any of the various Lund and
Browder diagrams.
Table 5 shows the variability by the type of rater
with the numbers re¯ecting the variances of replicate
measures of the same chart by raters of the same pro-
 T.L. Wachtel et al. / Burns 26 (2000) 156±170 163

Fig. 7. NBIE burn diagram and estimate sheet converted to a Rule of Nine's burn area chart (NBIE-9).

fession. There was no statistically signi®cant di€erence
among burn surgeons, physician's assistants and resi-
dents (Group I) or between burn nurses and other esti-
mators (Group II). Group II exhibited greater
variability than Group I which was statistically signi®-
cant.
Tables 6 and 7 show the e€ect of varying kinds of
burn experience on the estimates. Variation versus
months of burn experience is compared in Table 6.
Raters with 12±24 months of experience in burn care
show signi®cantly greater variability than those estima-
tors with less than 12 months experience or those esti-
mators with more than 24 months experience. The
latter two groups were not signi®cantly di€erent even
though there is a slight trend toward less variability in
those raters with greater than 24 months of burn ex-
perience. This indicates that ability to estimate burn
size could not be equated, directly, with months of
burn care experience. Variation versus number of
drawings made (a re¯ection of experience in making
and analyzing burn area drawings) is shown in Table
7. Those raters with more than 200 drawings show sig-
ni®cantly less variability than the other estimators for
total burn, slightly less for full thickness burn, but not
for partial thickness.
Plots of standard deviation in rating the burn draw-
ing as a function of mean burn size for each chart and
method is shown for partial thickness estimates (Fig.
8), full thickness estimates (Fig. 9) and total body sur-
face area burned (Fig. 10). Variability increases with
164 T.L. Wachtel et al. / Burns 26 (2000) 156±170

Table 1
Percent absolute areas ``burned'' for each burn area chart drawing as determined by planimeter and the mean and standard deviation of all 24
estimators for each of the ten burn area chart drawings on each of the six diagrams

A B C E H N R T U Z

Partial (28)
Planimeter 27.25 18.00 33.50 6.50 10.50 35.75 59.50 51.75 47.00 47.00
UCSD 26.7423.67 18.9723.76 33.172 3.84 5.14 21.48 11.7323.64 34.1723.25 59.182 7.25 50.4923.36 49.1924.45 43.972 4.88
UCSD-9 27.7523.90 20.8524.75 36.182 7.62 5.75 21.84 12.7523.85 35.4024.81 63.262 7.32 48.1325.02 47.3924.86 43.832 6.82
BTSB 25.4522.09 19.9822.52 35.422 3.72 5.83 21.57 12.8222.09 38.1423.98 61.662 3.64 50.9323.69 50.7823.92 48.992 2.64
CHI 24.8325.72 15.4322.60 33.022 5.93 5.71 21.83 10.7922.67 35.8025.68 59.102 5.43 53.0626.07 49.2524.65 48.742 4.73
NBIE 27.7423.00 19.8122.56 36.912 4.11 5.79 21.04 12.7122.15 35.2724.75 60.332 3.62 54.2324.02 50.1024.43 50.232 6.86
NBIE-9 28.5624.19 19.7822.06 36.312 4.22 6.55 22.21 13.9323.17 36.4526.66 64.982 6.43 53.7527.64 46.2229.06 45.482 2.93
Full (38)
Planimeter 23.25 3.00 27.50 2.00 9.50 42.75 14.50 36.25 47.25 14.75
UCSD 23.7322.98 3.6920.64 28.982 3.60 2.53 21.08 9.3322.69 40.4925.21 14.752 3.81 36.4623.57 39.73211.6 13.362 4.87
UCS-9 24.7021.93 3.6321.75 31.682 7.10 3.04 21.70 10.2122.53 43.7925.80 13.702 5.82 41.4723.14 45.9423.51 12.862 5.32
BTSB 25.2421.74 4.3626.03 29.032 3.74 2.72 21.03 10.3121.34 42.1724.52 12.932 1.20 37.1024.02 42.8823.58 14.662 3.14
CHI 24.1022.85 3.2220.78 29.142 3.99 2.34 20.94 9.8121.89 39.0724.55 13.222 2.05 34.3425.50 41.7923.83 13.352 1.99
NBIE 25.0321.82 3.2320.84 29.732 3.58 2.18 20.50 9.3021.73 42.6825.25 13.482 1.38 35.3124.37 44.1524.45 13.712 2.14
NBIE-9 25.7723.68 2.5320.75 31.272 4.09 2.30 20.79 11.7722.95 43.6025.80 12.182 3.29 36.5725.42 45.8229.62 16.502 2.82
Total (28+38)
Planimeter 50.50 21.00 61.00 8.50 20.00 78.50 74.00 88.00 94.25 61.75
UCSD 50.4624.59 22.6624.14 62.152 5.46 7.67 21.33 21.0625.50 75.0524.41 73.932 7.87 86.8124.95 89.00212.5 57.332 7.72
UCSD-9 52.3625.12 24.5525.80 67.812 11.5 8.54 23.63 22.9625.81 79.8527.23 76.962 5.30 90.0125.06 93.3224.67 57.142 8.99
BTSB 51.1923.48 23.1522.72 64.642 4.65 8.55 22.10 23.0822.46 80.3024.33 72.202 8.89 88.0122.03 93.7021.75 63.232 2.87
CHI 48.8526.62 18.6022.73 62.182 8.01 8.05 22.52 20.6023.88 74.8828.79 72.322 5.70 87.3125.59 91.0624.39 62.002 5.15
NBIE 52.7624.02 23.0422.94 67.092 6.46 7.97 21.04 22.0523.33 77.9324.37 73.912 3.66 88.9622.58 94.1321.51 63.732 6.45
NBIE-9 54.3323.22 22.2722.47 68.922 8.47 8.85 22.51 25.7024.36 80.1828.54 77.252 7.32 90.3327.08 92.0428.97 62.032 4.36

burn size and reverses the trend slightly in the very
large burns.
From the questionnaires we were able to obtain the
evaluators self-report on the number of months of
burn experience and how many burn area chart draw-
ings with estimates of burn size they had actually cre-
ated. The estimators thought that the tables on the
Lund and Browder diagrams were cumbersome to ®ll
in, but provided a good reference for determining the
size of a speci®c area. They preferred to write the esti-
mates of partial and full thickness burns in the white
space next to the burned area, connecting the estimate
number to the area with a line. It was faster to do the
estimates of the individual areas, but became confusing
and harder to sum the total areas of partial and full
thickness burns particularly for the larger burn rep-
resentations. The table allowed the estimator to
account for each burned area and aligned the estimates
in a column for easier summation, avoiding mathemat-
ical errors during addition. These drawings were in
black and white and di€erentiated the partial thickness
from the full thickness burn representation with
hatched or solid markings. The estimators uniformly
recommended that two di€erent colors (e.g. blue and
red) be used that were transparent enough to see
through so that the drawn landmarks and area delimi-
ters on the diagrams could be seen. They suggested
that the di€erent colors could also be used in the white
Table 3
Comparison of the mean burn estimates for total body surface area
burned for all estimators for ten di€erent ``burns'' using Lund and
Browder (L&B) and comparable Rule of Nine's diagrams (-9)
Case Planimeter UCSD UCSD-9 NBIE NBIE-9

Table 2 A 50.50 50.46 52.36 52.76 54.33

Variability of estimates versus type of chart useda B 21.00 22.66 24.55 23.04 22.27
C 61.00 62.15 67.81a 67.09 68.92
Chart Partial (28) Full (38) Total (28+38) E 8.50 7.67 8.54 7.97 8.85
H 20.00 21.06 22.96 22.05 25.70a
UCSD 3.96 4.01 5.86 N 78.50 75.05 79.85a 77.93 80.18
UCSD-9 5.08 3.86 6.32 R 74.00 73.93 76.96 73.91 77.25a
BTSB 2.99 3.03 3.53 T 88.00 86.81 90.01a 88.96 90.33
CHI 4.53 2.84 5.34 U 94.25 89.00 93.32a 94.13 92.04
NBIE 3.65 2.61 3.64 Z 61.75 57.33 57.14 63.73 62.03
NBIE-9 4.86 3.92 5.73
a
Size by Rule of Nine's di€ers signi®cantly from Lund & Browder
a
Entries are the averages of standard deviations from Table 1. size ( p < 0.05).
 T.L. Wachtel et al. / Burns 26 (2000) 156±170 165

Table 4
Mean time and standard deviation in minutes required to estimate the size of burn as a function of each of the ten burn area chart drawings on
each of the six diagrams used (the averages for each diagram are computed over all raters and over all drawings)

Diagram A B C E H N R T U Z Average

UCSD 8.6728.37 4.04 22.46 8.30 25.98 2.5022.28 3.65 23.12 6.772 4.98 4.4122.72 6.35 23.94 5.5824.04 6.67 24.43 5.692 4.23
UCSD-9 4.7522.99 5.50 25.03 8.21 25.04 1.9122.32 3.21 21.86 5.942 4.79 4.3323.19 4.79 22.96 4.4522.69 5.93 23.96 4.902 3.48
BTSB 7.1924.39 4.38 22.72 14.922 12.78 2.9423.89 4.67 23.10 8.872 6.63 5.5424.52 7.76 25.06 5.0922.79 6.65 24.59 6.802 5.04
CHI 5.5623.10 4.08 22.03 10.2527.44 3.5422.97 5.02 21.95 11.172 8.54 6.6725.64 7.89 25.16 6.8524.60 5.69 22.95 6.672 4.44
NBIE 5.0122.97 3.90 22.34 9.04 24.63 2.0422.09 5.48 22.92 10.332 4.64 6.3324.06 7.96 25.26 6.1723.68 6.89 23.83 6.322 3.64
NBIE-9 4.2223.33 2.39 21.23 5.11 23.78 1.9422.11 3.52 22.05 9.192 4.36 6.2724.17 7.69 25.14 6.1326.80 5.79 23.99 5.232 3.70

Table 5 Table 6
Variability by type of ratera Variability versus months of burn experiencea

Type of rater Partial (28) Full (38) Total (28+38) Number Months Partial (28) Full (38) Total (28+38) Number
of raters of raters

Group I Less than 12 17.55 12.83 23.27 8

Burn surgeons 12.46 6.99 13.56 4 12±24 25.31 18.47 41.61 4
Residents & PAs 10.47 6.56 11.77 4 More than 24 15.65 11.21 22.68 12
Group II
a
Burn nurses 20.22 17.17 32.20 11 Entries are the mean squares for error for the Chart by Method
Other estimators 25.82 13.69 34.53 5 interaction. Computations were made using the program BMDP2 V.

a
Entries are the mean squares for error for the Chart by Method
interaction. Computations were made using the program BMDP2 V.
space to indicate the estimated percentage of each
depth of burn (this methodology was the standard
practice on our burn unit). Other items from the ques-
tionnaires are re¯ected in the discussion.
4. Discussion
The reliability of estimates of burn size and depth is
a multifaceted problem of critical importance since this
estimate is central to all current appraisals of burn
severity [8]. Initially, an observer inspects the burn
wound, rating its color and texture, the presence or
absence of blistering, singeing of hair, etc. She or he
may test the wound for sensibility, loosened hair, wet-
ness or surface temperatures. These largely subjective
observations are recorded as partial thickness or full
thickness burns on a burn area chart. Finally, the
areas of partial thickness burn (second degree), full
thickness (third degree) and total body surface area
(second degree+third degree) burned are estimated
from the drawing, on the chart. Berry and others have
evaluated the sources of error and bias inherent in
transferring observations to burn charts [18,19]. The
thrust of our investigation was to examine the in¯u-
ence of some burn area charts currently in clinical use
on estimates of burn size and to evaluate the inter-
rater variability.
There are two main classes of clinical burn area
charts; those based on the Rule of Nine's [14] and
those modi®ed from Lund and Browder's more com-
plex system [11]. Our study examined four variations
of the Lund and Browder diagram. Of those, the
BTSB burn area chart shows less variability than the
other charts for partial thickness burn and for total
burn. The UCSD diagram more often approximated
the actual burn size determined by the planigram when
compared to the other burn area chart drawings. A
bias may have been the familiarity with the UCSD dia-
gram by the estimators. To eliminate such bias in any
future studies, the diagram used by the estimators'
own burn unit should be eliminated or the estimator
group should be much larger and derived from many
diverse burn centers.
Our study compared two versions of the Lund and
Browder burn area chart to their Rule of Nine's
counterpart. The variability of estimates using the
UCSD Lund and Browder burn area chart was less
than estimates using the corresponding Rule of Nine's
Table 7
Variability versus number of drawings madea
No. of Drawings Partial (28) Full (38) Total (28+38) Number of raters
Less than 50 17.23 14.07 24.93 12
50±199 20.58 14.56 36.56 6
200 or more 18.44 11.30 19.50 6
a
Entries are the mean squares for error for the Chart by Method
interaction. Computations were made using the program BMDP2 V.
166 T.L. Wachtel et al. / Burns 26 (2000) 156±170
Fig. 8. Variability showing standard deviation versus mean estimated burn size for the partial thickness areas.
chart for partial thickness burns and for total area
burned, but not for full thickness burns. The variabil-
ity of estimates for the Lund and Browder chart was
smaller for partial thickness, full thickness, and total
burn than were estimates using the Rule of Nine's
counterpart for the NBIE diagrams. Estimates from
the Rule of Nine's diagrams were least precise in
matching the actual area delimited by the planigram.
In our study the use of charts based on the Rule of
Nine's consistently led to a 3% larger burn estimate.
Conversely, estimation of the burned area can be
made in a shorter time using the Rule of Nine's.
There are some problems resulting in inaccuracies
that are common to all the charts studied. Most sig-
ni®cant is that all the charts require the representation
of a three dimensional burn on a two dimensional
drawing [20]. Lateral burns are not well represented on
such drawings and may in some cases constitute the
majority of the burned area. The area of the trunk is
too large to divide accurately and lacks sucient land-
marks to improve the precision of drawing and esti-
mating burn size in this region. Conversely, the
representation of hands (®ngers), feet (toes) and head
is too small to enable precision in recording (one of
the reasons for magni®ed views of hands and head on
the UCSD diagram and estimation). Our ten represen-
tative burn area chart drawings could be divided into
two groups based on burns of irregular shape or cover-
ing the trunk and/or legs versus less irregularly shaped
burns of more precise areas. The variability for the
estimates of the drawings of the ®rst group was greater
than the estimates for drawings of the latter group.
These di€erences were statistically signi®cant and sup-
port our hypothesis that the variability in rating irre-
gularly shaped burns covering large areas is greater
than for burns that are regularly shaped or on areas
that can be more precisely de®ned. Moreover, the
smaller anatomical areas de®ned by the Lund and
Browder charts and tables may have had decreased
variability and in¯uenced our results.
The inter-rater variability studies showed that there
was no statistically signi®cant di€erence among burn
surgeons, physician's assistants and residents or
between burn nurses and other estimators. The ®rst
professional group (Group I) exhibited less variability
than the second professional group (Group II), which
was statistically signi®cant. To investigate further, esti-
mators with 12±24 months experience in burn care
show signi®cantly greater variability than those estima-
tors with less than 12 months of burn experience or
 T.L. Wachtel et al. / Burns 26 (2000) 156±170
Fig. 9. Variability showing standard deviation versus mean estimated burn size for the full thickness areas. Numbers indicate presence of multiple
data points (stars).
those estimators with more than 24 months of burn ex-
perience. The latter two groups were not signi®cantly
di€erent and would indicate that ability to estimate
burn size could not be equated with burn care experi-
ence. Those raters who have created and estimated
burn size on more than 200 drawings showed signi®-
cantly less variability than the other estimators for
total burn but not for partial thickness or full thick-
ness burn separately. The ®rst group is the group of
people more often tasked with the initial burn area
chart drawing and estimate in our burn unit. This
leads us to conclude that the burn experience that
e€ects inter-rater reliability is derived from making the
drawings and the corresponding estimates rather than
from working with burned patients. Perhaps, the esti-
mates, if reasonable in depicting the burn, are accepted
as an accurate and useful appraisal by the burn team.
Plots of standard deviation in rating the burn as a
function of mean burn size show that variability
increases with burn size and reverses the trend only
slightly in the very large burns. These plots support
theoretical statistical reasoning [18] and the clinical im-
pression that estimating a small burned area is equival-
ent to estimating a small-unburned area. Perhaps the
167
shape and location of unburned areas in large burns
di€er from the shape and location of burned areas in
small burns. Since the shape and location of an area
in¯uences the accuracy with which it is estimated, the
accuracy of estimating large burns may be slightly
lower because these estimations implicitly involve esti-
mating the size of burned areas whose location and
shape make accurate area determinations more di-
cult.
The diagram itself introduces an additional error.
Planographic evaluation of the charts used in this
study reveals that the actual area of the diagram is not
the same as the percentage of body surface area it pur-
ports to represent. This error, however, is probably
minimized since, for estimating, the burn area chart
ascribes the actual percentage to the area and the esti-
mator describes the burn as a fraction of that percen-
tage.
Drawings on burn area charts and area estimates
from these drawings are useful not only in the initial
evaluation of the burned patient, but also to record
serially, the treatment and the progress of the wound.
Periodic evaluation may indicate changes in the area
or depth of the burn. At the time of the operative pro-
168 T.L. Wachtel et al. / Burns 26 (2000) 156±170
Fig. 10. Variability showing standard deviation versus mean estimated total body surface area burned.
cedure the burn area chart can be used to describe
accurately the areas grafted (autograft, allograft, xeno-
graft) and the location of donor sites, amputations,
etc. It has been customary in the past at the time of
discharge to record the total area of the second degree
and third degree burn (then healed) and to equate the
grafted areas with third degree burn. It is no longer
accurate to correct the initial estimate of third degree
burn as that area ultimately grafted. The reason is that
modern treatment such as the early use of enzymatic
debridement or sequential excision and grafting [21,22]
may result in larger areas being grafted (to obtain a
better functional or cosmetic result or more rapid clo-
sure of the burn wound) than would have been
required when second degree areas were allowed to
heal and the eschar was permitted to separate before
the open granulating areas were grafted. Recently, the
area of burn size has been used to predict length of
hospital stay [23], a rough re¯ection of the cost of
burn care.
Because the treatment regimen itself may a€ect the
area which ultimately requires grafting and because of
our methods of diagnosing partial thickness (second
degree) and full thickness (third degree) injury early
after the burn are primitive at best, there is no absol-
ute standard by which to evaluate the accuracy or the
degree of error introduced by the burn chart chosen.
One can only evaluate the ease of use, the consistency
of results between observers, and the bias introduced
by the chart into the estimate. Nevertheless, knowledge
of these descriptors contributes to the evaluation of
the meaning of comparisons between series of burned
patients. We believe that there should be a standard
system for the estimation of burn size adopted and
used nationwide (and perhaps worldwide) in order that
future studies of burns be more universally meaningful.
Feller pioneered such a system through the NBIE [8].
We believe that the American Burn Association and
the International Society for Burn Injuries should
adopt such a universal system.
There is no question that, for the purposes of
research, some reliable form of documenting burn size
should be commonly accepted among burn care provi-
ders. The calculation of burn size, even using the most
sophisticated systems, contains a certain amount of
subjective evaluator bias. The Lund and Browder
charts, which provide percentages of body surface area
for given body parts and relative to age are thought to
be the most accurate method of estimating burn size.
But it is just that, an estimation. Fluid resuscitation
formulae, although partly based on burn area, are
used only to initiate ¯uid therapy and as a guide to
 T.L. Wachtel et al. / Burns 26 (2000) 156±170
¯uid replacement, not the absolute rule. Consequently,
exact burn area is really not extraordinarily clinically
relevant, but more necessary from an epidemiological
perspective so that comparisons between treatment
methods, morbidity, mortality, and other outcomes
can be more clearly demonstrated.
We can speculate that there may be better ways to
accomplish the task of making a burn area drawing
and estimation [24±27]. The training of a medical artist
combined with the expertise of an experienced burn
surgeon would probably permit more accurate con-
struction and recording of the burn area chart draw-
ings. Alternatively the use of standard ®xed focal
length pictures (i.e. ``scanned in'' photographs or digi-
tal images) of the back, front, and left and right sides
of a burned patient with a measuring grid incorporated
into the picture to determine the height of the patient
and the size of the burned area may lead to more
accurate appraisals of the size of the burn wounds.
Comparative photographs could be made at set inter-
vals and at discharge. Computerized mapping devices
could be used to accurately depict the size and location
of the burns [28,29]. These techniques would give
rapid, precise, permanent recordings of the patient and
the burned areas. The pictures could be made expedi-
tiously during admission when other priorities often
preclude construction of an accurate and precise burn
area chart drawing. Later an accurate determination of
the burn areas could be made using the mapping tech-
niques [24] modi®ed according to the information not
elicited by color photography (sensation to pin prick,
pliability, capillary ¯ow, etc.). The use of a computer
to calculate each anatomical regional percentage and
accurately sum for partial thickness, full thickness and
total area burned is required [28]. The cost of such a
system must be weighed against the value of the pro-
duct (precise burn area estimates) and the use for
which the data are obtained. If the estimate continues
to be performed by hand, some systematization would
be helpful. This model diagram and methodology
would include a standardized Lund and Browder burn
area chart with the exploded detail of the UCSD form
and the anatomically de®ned, age speci®c table of the
NBIE or BTSB form. Furthermore, if these data are
important, as they seem to be, a standardized, accurate
method of determining the size of the burn area must
be employed on a widespread basis.
Acknowledgements
All the estimators; Yolanda Crespin; Diana
Dillinger; Ronda Glazebrook; Amy Sauer; Carolyn C.
Wachtel, RN; Susan Wiggins.
HAS-DHEW Grant No. 240-77-0158 to UCSD sup-
ported this research.
169
Presented to the Tenth Quadrennial Congress of the
International Society for Burn Injuries, Jerusalem,
Israel, November 2, 1998.
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