burns 41 (2015) 890–906

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Review

The use of split-thickness versus full-thickness

skin graft to resurface volar aspect of pediatric
burned hands: A systematic review

Theddeus O.H. Prasetyono a,*, Patricia M. Sadikin b, Debby K.A. Saputra b

a
Division of Plastic Surgery, Department of Surgery, Cipto Mangunkusumo Hospital/Faculty of Medicine University of
Indonesia, Jakarta, Indonesia
b
Diponegoro 71, Jakarta 13410, Indonesia

article info abstract

Article history: Objective: The aim of this systematic review was to discuss the comparison of split-thick-
Accepted 15 January 2015 ness skin graft (STSG) and full-thickness skin graft (FTSG) use as the treatment for volar
digital and palmar burns in children.
Keywords: Methods: We conducted PubMed and Cochrane Library searches using keywords ‘‘hand
Hand injuries injuries’’, ‘‘contracture’’ and ‘‘skin transplantation’’. The search was limited to studies
Contracture published from 1st January 1980 until 31st December 2013 and used English language.
Skin transplantation We selected the studies based on specific inclusion and exclusion criteria. We assessed the
quality of the studies by using Newcastle–Ottawa Scale (NOS) for cohort studies.
Results: We included eight articles in our systematic review. One of those studies is a
prospective cohort study and the others are retrospective cohort studies. Based on com-
bined range of motion (ROM) evaluation in three studies, STSG group yielded poorer
functional outcomes than FTSG group. However, there is no study which can fairly show
that FTSG was significantly superior to STSG to achieve good functional outcomes.
Conclusion: Currently, there is no strong, high-quality evidence to prove that FTSG is super-
ior to STSG to cover pediatric palmar burns. Either FTSG or STSG can be utilized with
consideration of several influential factors especially splinting and physiotherapy.
Type of study/level of evidence: Therapeutic, II.
# 2015 Elsevier Ltd and ISBI. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891

* Corresponding author at: Division of Plastic Surgery, Department of Surgery, Cipto Mangunkusumo Hospital/Faculty of Medicine
University of Indonesia, Medical Staff Building 4th floor, Jl. Diponegoro 71, Jakarta 13410, Indonesia. Tel.: +62 817858899; fax: +62 21
31903152.
E-mail addresses: teddyohprasetyono@yahoo.com (Theddeus O.H. Prasetyono), patricia_marcellina@yahoo.co.id (P.M. Sadikin),
db.k.adi.saputra@gmail.com (Debby K.A. Saputra).
http://dx.doi.org/10.1016/j.burns.2015.01.011
0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
 burns 41 (2015) 890–906 891

2.1. Search and selection processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891

2.2. Data extraction and quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 891
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892
3.1. Outcome evaluation – ROM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 893
3.2. Methodological quality of the included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 894
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 894
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 897
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906

formation of contracture due to poor compliance of long-term

1. Introduction night splint use. The aim of this systematic review is therefore
to investigate studies comparing STSG and FTSG use to
Burn is one of the most common cases in plastic surgery resurface the fingers and palm burns in pediatric hands in
which has various and prolonged sequelae especially in terms of functional outcomes and esthetic appearances. We
children. It is the fifth most common cause of non-fatal considered conducting this systematic review because we try
injuries in childhood [1]. Worldwide, it is estimated that to provide a higher level of evidence, comparing FTSG and
over half a million children are hospitalized with burns STSG, since most of the available studies do not exceed level
every year [2]. In low- and middle-income countries, III evidence.
approximately one-third of overall burn cases comprised
children younger than 4 years old [3]. Children have higher
risk to get burns especially in upper extremities because 2. Methods
naturally they are active and curious to explore their
surroundings with their hands but they have slow with- The systematic review method was made based on the
drawal reflexes which cause them to have prolonged Preferred Reporting Items for Systematic Reviews and Meta-
contact with heat sources resulting in a deeper burn [3–5]. Analyses (PRISMA) guidelines (www.prisma-statement.org)
Burns in children mostly are caused by scald from hot [13].
liquids, flame, and direct contact with hot objects in which
the latter can cause deep burns to the palms [6,7]. 2.1. Search and selection processes
Most of superficial pediatric hand burns can be treated
with topical antibiotics, dressing, and splinting, however, in Studies comparing the use of FTSG and STSG for covering
cases of deep partial and full thickness burns, surgical burns of the volar aspects of the hand in children were our
interventions are needed to close the wound [4,8,9]. main interest. Papers reporting hand injuries inflicted by
Modalities available to cover deep palmar hand burns are causes other than burns and burns to the dorsum of the
skin grafts and flaps. Surgeons utilize skin grafts more often hand were excluded. We also excluded studies which
than flaps because the cases of pediatric burned hand which discussed flaps and the use of either FTSG or STSG alone,
need flaps to cover the wound are rare. However, the nature case reports/series, narrative review, letter to editor, and
of skin grafts is to develop secondary contracture [7]. It is articles without available full-text. The assessed outcomes
aggravated by the nature of the hand to flex in resting were in the form of functional outcomes including range of
position (intrinsic minus posture) due to relatively greater motion (ROM), incidence of contracture/re-contracture, and
strength of the flexor musculature [5,10]. This flexion esthetic outcomes.
contracture is undesirable since it will give long-term PubMed and the Cochrane Library search were conducted
impacts toward children’s hand function and psychosocial in February 2014. The publication date was limited from 1st
well-being [11]. January 1980 until 31st December 2013. Only articles published
Several methods have been applied to immobilize the in English were included in this study. A specific search term
hands and prevent the formation of flexion contracture (in Appendix) was developed using keywords ‘‘hand injuries’’,
such as splinting, exercising, and pressure garments [7,8]. ‘‘contracture’’, and ‘‘skin transplantation’’ so that no relevant
During rehabilitation period, the hand is splinted in position study was missed. The title and abstract of retrieved articles
of extended wrist and hyperextended metacarpophalangeal were screened by applying inclusion and exclusion criteria
(MP) and interphalangeal (IP) joints of digits 2–5 to maintain and full-text of relevant articles were obtained. Furthermore,
antideformity position [12]. Unfortunately, it is difficult to the reference list from each relevant study was also screened
get cooperation from children to comply to the regimen for potentially suitable studies. Each included study was
therefore some degrees of contracture will still develop [10]. scrutinized by three reviewers (TOHP, PMS, and DKAS) and
The use of either split-thickness (STSG) or full-thickness difference in opinion was settled through consensus. (Fig. 1)
skin grafts (FTSG) as a wound closure has its own benefits and
drawbacks. Controversy regarding which type of skin grafts is 2.2. Data extraction and quality assessment
better to achieve good functional and esthetic outcomes in
pediatric palmar hand burns is still present [11]. Based on our A data extraction table was created to extract data from
clinical experiences, the use of FTSG will still result in the each article. We collected data on study design, patients’
892 burns 41 (2015) 890–906

Fig. 1 – Summary of screening process. Searching in PubMed and the Cochrane Library yielded 663 results. From those
results, 8 studies were included in this systematic review after screening process for title and abstract, full text, and manual
screening of references as well.

characteristics, methods of skin grafting, methods of postop- review. There are three major components of this scale,
erative therapy, and outcome measures from all included namely selection of the groups of study, comparability, and
studies. assessment of the outcome.
Patients’ characteristics included age, location of burns,
and mechanism of injury. Methods of skin grafting comprised
information regarding time from burns to skin grafting, origins 3. Results
of skin grafts, and time of follow-up. Methods of postoperative
therapy were defined as any treatments performed after the From PubMed and Cochrane Library searches, there were a
skin grafting especially physiotherapy and splinting. Outcome total of 663 articles retrieved. After applying inclusion and
measures were defined as any measurements used to assess exclusion criteria to the title and abstract, 28 articles were
the outcomes after the skin grafting. selected. Eighteen articles [8,10,15–30] which did not meet the
We used the Newcastle–Ottawa Scale (NOS)[14] for asses- inclusion criteria and 2 articles [31,32] which did not have
sing the quality of the included studies in this systematic available full-text were excluded. Therefore, only 8 articles
 burns 41 (2015) 890–906 893

Table 1 – Summary of included studies.

Authors and year Type of study Number of Average age Number of Location Mechanism
of publication patients hands of burns of injury
(hands) discussed in
this review
Chan et al. (2013) [11] Prospective 26 (26) FTSG: 23.9 mo FTSG: 12 3 groups: contact,
(range, 10–54 mo) STSG: 10 (a) palm, treadmill,
STSG: 34.1 mo (FTSG + STSG: (b) volar digital, friction,
(range, 4–192 mo) 4, included in (c) palm and scald, flame
each type) volar digital
Chandrasegaram Retrospective 174 (172) <6 yo (78.7%) FTSG: 12 3 groups: Contact,
et al. (2009) [34] FTSG: 46 STSG: 29 (a) Hand grafts friction,
STSG: 126 (excluding (palmar and/or scald, flame,
(FTSG + STSG: dorsal of dorsal grafts electrical,
2, excluded) hands) excluding digits), chemical
(b) digit grafts,
(c) hand and digit
grafts (grafts to
palm and/or
dorsum including
digits)
Al-Qattan (2009) [35] Retrospective 53 (82) Burn: 9 mo FTSG: 56 Palm and palmar Campfire
(range, 5–12 mo) STSG: 26 aspect of the digits
Contracture
release: 23 mo
(range, 7–40 mo)
Jang et al. (2001) [36] Retrospective FTSG: 36 (36) FTSG: 10.8  FTSG: 36 Palmar, web, Electrical rice
STSG: 79 (79) 2.8 mo STSG: 53 fingers cooker steam
STSG: NA
Roh et al. (2000) [37] Retrospective 79 (81) 10.5 mo (range, FTSG: 14 palmar, digits, Electrical rice
7 mo-4.5 yo) STSG: 36 dorsala cooker steam
Schwanholt et al. (1993) Retrospective 24 (30) FTSG: 35  12 mo, FTSG: 14 Palmar NA
[38] STSG: 47  16 mo STSG: 16
Pensler et al. (1988) [39] Retrospective 25 (25) Contracture FTSG: 11 Palmar NA
release: STSG: 14
FTSG: 3.5 yo
STSG: 3.6 yo
Merrell et al. (1986) [5] Retrospective 12 (13) 13 mo (range, FTSG: 8 Palmar Contact with
9–24 mo) STSG: 3 hot surfaces
FTSG: full-thickness skin graft; mo: months old; NA: not available; STSG: split-thickness skin graft; yo: years old.
a
Two hands involved dorsal aspect of the hand.

were obtained. Manual screening of the references of those 8 Most of the causes of palmar hand burns are contact with
articles was also conducted and 1 article[33] was found to be hot surfaces and they were mostly suffered by children aged
suitable for this review; however, the full text cannot be below 5 years old. Mean time from burns to skin grafts was
obtained. Finally, a total of 8 articles were included for review approximately 2–3 weeks. The source of FTSG was mostly
in this paper [5,11,34–39] (Table 1). from the groin and STSG was from the thigh. Average time of
The included studies consist of 1 prospective cohort study follow up is more than 6 months (Table 1).
[11] and 7 retrospective cohort studies [5,34–39]. Six articles Overall, there are 6 studies [5,34–38] which showed that the
[5,11,34,36–38] discussed early excision and skin grafting and hands in FTSG group had less contracture rate compared to
2 articles [35,39] addressed contracture release and skin hands in STSG group. However, the study by Al-Qattan [35]
grafting of pediatric palmar hand burns. Five studies used a protocol in which STSG was used in more severe burn,
[5,11,34,35,38] applied splinting with various methods and 4 i.e. larger and deeper burns. Studies by Jang et al. [36], Roh et al.
studies [5,11,34,38] applied physiotherapy as the post-opera- [37], and Merrell et al. [5] did not apply statistical analysis. Two
tive management (Table 2). One study [36] did not use studies [11,39] demonstrated no significant difference in
splinting and 2 studies [37,39] did not explain about the contracture rate between FTSG and STSG group (Table 3).
splinting and physiotherapy application. Objective outcome
measurements were used by 3 studies; 2 studies [38,39] used 3.1. Outcome evaluation – ROM
ROM and 1 study [11] used Vancouver Scar Scale (VSS), while
the other studies used subjective measurements in the form ROM to evaluate the functional outcomes was used in 3
of incidence of contracture/re-contracture and received studies. Merrell et al. [5] classified the ROM qualitatively
secondary reconstructive procedures (Table 3). based on degree of disability while the other two studies
894 burns 41 (2015) 890–906

Table 2 – Procedures performed in each study including additional therapy especially splinting methods.
Authors and year Mean time from Origin of SG Physiotherapy and Mean time of
of publication burns to SG splinting methods follow-up
Chan et al. (2013) [11] 11 days FTSG: groin and Standard physiotherapy and FTSG: 12 months
inner arm thermoplastic palmar STSG: 15 months
STSG: inner arm, extension splint
thigh, and back
Chandrasegaram 3 weeks NA Maximal physiotherapy NA
et al. (2009) [34] and serial splinting
Al-Qattan (2009) [35] Contracture FTSG: groin Physiotherapy NA; night 6 months to 10 years
release STSG: thigh extension splint
Jang et al. (2001) [36] FTSG: immediate FTSG: inguinal Compressive pressure FTSG: 8.77  4.8 months
STSG: NA area glove; no splinting and (range 3–25 months)
STSG: NA physiotherapy STSG: NA
Roh et al. (2000) [37] FTSG: 14.8 days, FTSG: groin NA NA
STSG: 17.5 days STSG: scalp
or thigh
Schwanholt et al. FTSG: 11.0  1.8 days FTSG: inguinal ROM exercises 5 days after FTSG: 23  2 months
(1993) [38] STSG: 10.5  2.2 days region surgery, home exercise STSG: 38  4 months
STSG: back 6/day; extension hand
or thigh splints with cohesive wrap
Pensler et al. (1988) [39] Contracture release NA NA FTSG: 4.7  2.0 years
STSG: 6.0  3.2 years
Merrell et al. (1986) [5] 18 days FTSG: lateral Active ROM exercises, 17 months (range
portion of groin daily physical therapy, 4 months to 6 years)
STSG: NA compression gloves;
nocturnal ‘‘sandwich
splinting’’
FTSG: full-thickness skin graft; NA: not available; ROM: range of motion; STSG: split-thickness skin graft.

[38,39] classified it quantitatively based on degree of The outcomes were assessed by independent blind
contractures. Therefore, the result of Merrell’s study might assessment in 1 study [11] and by record linkage in 5
be prone to error of subjectivity. Schwanholt et al. and studies [5,34,37–39] while 2 studies [35,36] did not describe
Merrell et al. classified the ROM into 4 categories (excellent/ their methods of outcome assessment. The length of follow
full, good, fair, and poor) while Pensler et al. classified the up for outcomes to occur was set to at least 6 months and it
ROM into 3 categories (good, fair, and poor). Based on the was fulfilled in 6 studies [5,11,35,36,38,39] while 2 studies
description of the categories in each study, it is possible to [34,37] did not mention their length of follow up. Seven
merge the classification of those 3 studies into a new studies [5,11,34,35,37–39] had complete follow up for all
classification, which are good to excellent, fair, and poor. subjects and 1 study [36] gave no information on lost at
From those 3 studies, there were 66 palms operated; follow up.
33 palms in each FTSG and STSG group. Good–excellent In summary, the quality of the included studies was
result was obtained by 78.8% (26/33) of all hands in FTSG adequate in terms of selection of the study groups and
group and 60.6% (20/33) of all hands in STSG group. One assessment of the outcome based on the NOS criteria for
hand (3%) in each group developed fair ROM. There are cohort studies. However, the component of comparability in
more hands in STSG group which were graded poor those studies could possibly induce bias in this systematic
compared to hands in FTSG group (36.4% vs 18.2%, review (Table 4).
respectively).

3.2. Methodological quality of the included studies 4. Discussion

All studies involved truly and somewhat representative The ideal management of pediatric hand burns is very
exposed cohort of the average children with burns to the crucial for optimal functional and esthetic outcomes of the
volar aspect of the hands receiving skin grafts in the hands of the fast-growing children; yet some of the issues
community. All but one study [36] obtained the non-exposed are still debatable. In this review, the option to use FTSG
cohort from the same community as the exposed cohort. or STSG for covering the volar aspect of hand burns in
All but 3 studies ascertained the exposure by secure children is discussed.
record (medical records), one by structured interview [11], The current trend is to use FTSG as the wound coverage
and two did not describe the method of ascertainment for the pediatric hand burns because it is believed that it
[35,36]. No studies mentioned adjustment for any con- has less secondary contracture rate and decreases the need
founding factors. of secondary reconstructive procedure; however, FTSG
 burns 41 (2015) 890–906 895

Table 3 – Outcomes of each study.

Authors and year Outcomes Significance Conclusion
of publication level
Outcome measures FTSG STSG
Chan et al. (2013) [11] VSS – pliability Sig. enhanced P < 0.01 Improve outcome after FTSG
in FTSG although except for pliability,
VSS – elevation, vascularity, No. sig. P = NA the differences were small
pigmentation difference
Texture Better in STSG P = NA
but no sig.
difference
Hair growth Sig. in FTSG P = 0.002
Contracture (palm only) 0/4 0/3 No statistical
analysis
Contracture (digits only) 1/7 1/6
Contracture (palm 3/5 3/5
and digits)

Chandrasegaram Contracture* 1/12 12/29 P = 0.039** Promote the use of FTSG

et al. (2009) [34] Secondary scar releasey 1/12 7/29 P = 0.241z especially the hand burns
involving the surface of the palm
and extends into the digits

Al-Qattan (2009) [35] Contracture 32/56 20/26 No statistical STSG group underwent more
analysis secondary surgery than FTSG
Second release and 3/32 10/20 P = 0.003 group; more likely due to the
grafting more severe burn in the STSG
group rather than the type of
graft used

Jang et al. (2001) [36] Finger joint and web 6/36 42/53 No statistical Primary FTSG may be a reliable
space contracture analysis method to cover acute severe
burn in pediatric patients

Roh et al. (2000) [37] Correction for flexion 0/14 18/36 No statistical Unable to draw conclusion
contracture and analysis regarding which type of skin graft
web release gives better functional outcomes

Schwanholt et al. Full ROM 8/14 4/16 P = 0.078 – Improve function and decrease
(1993) [38] ROM score (median) 0 1.5 P = 0.025 need for reconstructive
Secondary reconstructive 3/14 10/16 P = 0.028 procedures with FTSGs
surgical procedure
– The combination of FTSGs,
application of extension splints,
and vigorous stretching was the
optimal treatment for isolated
palmar burns in young pediatric
patients

Pensler et al. (1988) Functional results Good Good No sig. STSG was comparable with FTSG
[39] difference, in functional outcome and
P = NA further operative procedures
Number of operations 1.3  0.06 1.2  0.4 No sig.
operations operations difference,
P = NA

Merrell et al. (1986) [5] Functional (ROM) 7/8 excellent, 2/3 good, No statistical Promote the use of FTSG with
1/8 fair (scar 1/3 fair analysis aggressive physical therapy
hypertrophy
of a digit)
Cosmesis (general 4/8 excellent, 2/3 good,
appearance, contour, 4/8 good (small 1/3 fair
and color match) areas of scar
hypertrophy)
FTSG: full-thickness skin graft; NA: not available; ROM: range of motion; sig: significant; STSG: split-thickness skin graft; P: P-value; VSS:
Vancouver Scar Scale.
*
Incidence of volar contracture: FTSG: group A: 1/7, group C: 0/5; STSG: group A: 4/17, group C: 8/12.
**
Statistical analysis using Fisher’s exact test, 1-sided.
y
Incidence of secondary scar release of volar contracture: FTSG: group A: 1/7, group C: 0/5, STSG: group A: 1/17, group C: 6/12.
z
Statistical analysis using Fisher’s exact test, 1-sided.
896 burns 41 (2015) 890–906

Table 4 – Methodological quality assessment using the reconstruction excluding web spaces regardless the number of
Newcastle-Ottawa Scale (NOS). injured fingers. On the other hand, the use of STSG is
Studies (Year) Components considered in burns affecting more than two fingers that
include the web spaces. In addition, the outcomes of pediatric
Selection Comparability Outcome
hand burns are also affected by the application of physiother-
Merrell et al. (1986) $$$$ 0 $$$ apy/exercise and splinting.
[5]
Postoperative therapy in the forms of physiotherapy/
Pensler et al. (1988) $$$ 0 $$$
exercise and splinting is recommended to be integrated in
[39]
Schwanholt $$$$ 0 $$$ the management of pediatric volar hand burns even though
et al. (1993)[38] its success depends on the patient’s and family’s compli-
Roh et al. (2000)[37] $$$$ 0 $$ ance. In this review, 3 studies [5,11,38] applied extension
Jang et al. (2001)[36] $ 0 $ splints and physiotherapy to the patients but one study [36]
Al-Qattan (2009)[35] $$ 0 $$ deliberately did not implement any physical therapy or
Chandrasegaram $$$$ 0 $$
splinting method. It is reasoned that patients in the age
et al. (2009) [34]
Chan et al. (2013) $$$$ 0 $$$
group younger than 12 months old were uncooperative and
[11] the beneficial effects of those therapies could not be
expected. Our center also applies night extension splint as
the postoperative treatment but sometimes some degree of
flexion contractures still developed because younger chil-
possesses some limitations in its use. FTSG has limited donor dren did not fully extend their fingers. We recommend the
sources; therefore it cannot be used to cover large surface area use of ‘‘sandwich’’ splinting [5] with additional pads inside
of burns. It also has a lower take rate compared to STSG that follow the contour of the fingers to not only keep them
because of edema and inflammation reactions. Furthermore, in full extension position but also prevent the occurrence of
the wound that is covered with FTSG will be more hairy pressure sores and pain. We also perform physiotherapy in
because it also includes the hair follicles. STSG also owns some the form of purposeful activity based on playing or play
drawbacks such as a higher rate of secondary contracture and therapy for the children. It is a very useful strategy to attract
relatively less esthetic value. However, the use of STSG is the interest of children and break down barriers between the
advantageous in the sense that it can cover large area and has child and therapist. Most importantly it can be used to
a good take rate. The presence of infection will also affect the promote active hand movements. A study performed by
survival of the graft especially in FTSG due to its lower graft Omar et al. supports the use of purposeful activity based on
take rate [40]. Therefore, STSG may be more favorable, playing in the rehabilitation of children with hand burn
particularly for burn patients in developing countries where because it is more effective to reduce pain and improve hand
the risk of surgical site infection is high [41]. From the functions compared to rote exercise [42].
experience of the first author, patients still suffered from The quality of the studies discussed in this review is not
certain degree of secondary contracture regardless the type of ideal. The included studies were few in number and lack
skin grafts utilized unless optimal physiotherapy and splint- in quality. They are mostly retrospective cohort study with
ing were applied diligently. However, the lack of compliance small sample size. The heterogeneity of study populations
from children made physiotherapy and splinting difficult to be and outcomes also hinder comparisons. Almost all studies
applied. lacked a standardized objective measurement to analyze
From the included studies, there is no agreement regarding the outcomes. The rate of contracture/re-contracture and
the best skin graft type to cover the pediatric volar hand burns. secondary reconstructive procedure are mostly used as
Chan et al. [11] states that except for scar pliability, there was the outcome measures. They are considered subjective
no significant difference between FTSG and STSG in the because they were based on the opinion of the evaluator(s)
outcomes of deep palm burns in children. Chandrasegaram and sometimes it was influenced by the improvement of
et al. [34] supports the use of FTSG particularly in palmar burns functional outcomes of the patients after the surgery. Some
that extend into the digits. The study conducted by Al-Qattan examples of standardized objective tests to evaluate the
[35] is considered bias because the protocol was to use FTSG for hand are total active motion (TAM) and total passive motion
small wounds and STSG for large defects. The impacts of graft using standard dorsal goniometer to measure ROM. There is
types on the outcomes cannot be elucidated in Jang et al. [36], also missing information in some of the studies such as
Roh et al. [37], and Merrell et al. [5] studies because there were the number of subjects [36], performed additional therapies
no statistical analysis. Pensler et al. [39] encourages the use of [37,39], the number of operating surgeon(s), and the number
STSG while Schwanholt et al. [38] promotes the use of FTSG for of outcome assessor(s) [5,34–39]. This systematic review is
deep palm burns in pediatric patients. We can deduce from also subjected to bias because only English and published
those studies that the use of FTSG or STSG for pediatric volar studies included.
hand burns is influenced by several factors, namely surgeon’s Based on this systematic review, currently there is no
preference and experience; the depth and extent of the hand strong, high-quality evidence to prove that FTSG is superior
burns; and also the location of the burns whether it involves to STSG to cover pediatric palmar burns. The current
the web spaces and crosses the joints or not. The latter factor practice that FTSG is better than STSG to resurface burned
is also supported by a study performed by Park et al. [15] which volar hand in children cannot be justified. Either FTSG or
concluded that primary FTSG is recommended for volar finger STSG can be utilized with consideration of several factors
 burns 41 (2015) 890–906 897

mentioned above. The optimal postoperative therapy

(splinting and physiotherapy) is also imperative in this Conflict of interest
case. This systematic review also reveals a need for future
research, preferably through randomized controlled trials No conflict of interest.
using standardized objective measurements to show a
better comparison between FTSG and STSG.
Acknowledgement

Funding The authors would like to thank Ade Sari Nauli Sitorus, M.D.
for her contribution in initiating this systematic review
We conducted this systematic review with personal funding. proposal.
 898
Appendix A

Search terms in PubMed

(‘‘Hand Injuries’’[Mesh] or ((Hand[MeSH] or hand*[TIAB] or palm*[TIAB] or finger*[TIAB]) and (Injur*[TIAB] or ‘‘Contracture’’[Mesh] or contracture*[TIAB] or scar*[TIAB]))) and
(‘‘Skin Transplantation’’[Mesh] or ‘‘split thickness skin graft’’[TIAB] or STSG[TIAB] or ‘‘full thickness skin graft’’[TIAB] or FTSG[TIAB])
Limit: language (English), Publication date: 1st January 1980 to 31st December 2013
Search terms in Cochrane Library
(‘‘hand injuries’’ or ((hand or palm or finger) and (injury or contracture or scar))) and (‘‘skin transplantation’’ or ‘‘split thickness skin graft’’ or STSG or ‘‘full thickness skin graft’’ or
FTSG)
In Title, abstract, keywords
Quality assessment scale (Newcastle–Ottawa Scale)

Study (author and year): Merrell, 1986 [5]

Selection Comparability Outcome

Representativeness Selection of the Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
of the exposed cohort non-exposed of exposure outcome of interest cohorts on the of outcome long enough up of cohorts

burns 41 (2015) 890–906

cohort was not present at basis of the design for outcomes
start of study (for or analysis to occur
contracture)

(a) Truly representative (a) Drawn from (a) Secure record (a) Yes$ (a) Most important (a) Independent (a) Yes (at least (a) Complete follow
of the average children the same (e.g. clinical records)$ factors of adjustment $ blind assessment $ 6 months)$ up – all subjects
with burns to the volar community as (b) No (age, extent of the accounted for$
aspect of the hands the exposed (b) Structured burns, the use of (b) Record linkage$ (b) No
receiving SG in the cohort$ interview $ physiotherapy (b) Subjects lost to
community $ and splinting) (c) Self-report (for follow up unlikely
(b) Drawn from (c) Written self side effects) to introduce bias
(b) Somewhat a different source report (b) Any additional (lost to follow-
representative of the factor $: (origins of (d) No description up 5%) $
average children with (c) No description of (d) No SG, time of follow-up)
burns to the volar the derivation of the description (c) Subjects lost to
aspect of the hands non exposed cohort follow up >5% and
receiving SG in the description provided
community $ of those lost

(c) Selected group of children (d) No statement

with burns to the volar
aspect of the hands due to
specific causes e.g. chemical
or electrical injuries

(d) No description of the

derivation of the cohort

Selection: $$$$.
Comparability: 0.
Outcome: $$$.
 Study (author and year): Pensler, 1988 [39]

Selection Comparability Outcome

Representativeness Selection of the Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
of the exposed non-exposed of exposure outcome of interest cohorts on the of outcome long enough up of cohorts
cohort cohort was not present at basis of the design for outcomes
start of study (for or analysis to occur
contracture)

(a) Truly (a) Drawn from the (a) Secure record (a) Yes $ (a) Most important (a) Independent (a) Yes (at least (a) Complete follow up –
representative same community (e.g. clinical factors of adjustment $ blind assessment $ 6 months)$ all subjects accounted
of the average as the exposed records)$ (b) No (age, extent of the burns, for $
children with cohort $ the use of physiotherapy (b) Record linkage$ (b) No
burns to the (b) Structured and splinting) (b) Subjects lost to follow
volar aspect of (b) Drawn from a interview $ (c) Self-report (for up unlikely to introduce

burns 41 (2015) 890–906

the hands different source (b) Any additional factor side effects) bias (lost to follow-up
receiving SG in (c) Written self $: (origins of SG, time 5%) $
the community $ (c) No description of report of follow-up) d) No description
the derivation of the (c) Subjects lost to follow
(b) Somewhat non exposed cohort (d) No description up >5% and description
representative of provided of those lost
the average
children with burns (d) No statement
to the volar aspect
of the hands
receiving SG in the
community $

(c) Selected group of

children with burns
to the volar aspect
of the hands due to
specific causes e.g.
chemical or
electrical injuries.

(d) No description of
the derivation of the
cohort

Selection: $$$.
Comparability: 0.
Outcome: $$$.

899
 900
Study (author and year): Schwanholt, 1993 [38]

Selection Comparability Outcome

Representativeness of Selection of the Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
the exposed cohort non-exposed of exposure outcome of interest cohorts on the basis of outcome long enough for up of cohorts
cohort was not present at of the design outcomes to
start of study (for or analysis occur
contracture)

(a) Truly representative of (a) Drawn from the (a) Secure record (a) Yes$ (a) Most important (a) Independent blind (a) Yes (at least (a) Complete follow
the average children with same community as (e.g. clinical factors of adjustment $ assessment $ 6 months)$ up – all subjects

burns 41 (2015) 890–906

burns to the volar aspect the exposed cohort $ records)$ (b) No (age, extent of the burns, (b) Record linkage$ accounted for $
of the hands receiving SG the use of physiotherapy (b) No
in the community$ (b) Drawn from a (b) Structured and splinting) (c) Self-report (for (b) Subjects lost to
different source interview $ side effects) follow up unlikely
(b) Somewhat representative (b) Any additional factor to introduce bias
of the average children with (c) No description of (c) Written self $: (origins of SG, time (d) No description (lost to follow-up
burns to the volar aspect the derivation of the report of follow-up) 5%) $
of the hands receiving SG non exposed cohort
in the community $ (d) No description (c) Subjects lost to
follow up >5% and
(c) Selected group of children description provided
with burns to the volar aspect of those lost
of the hands due to specific
causes e.g. chemical or (d) No statement
electrical injuries

(d) No description of the

derivation of the cohort

Selection: $$$$.
Comparability: 0.
Outcome: $$$.
 Study (author and year): Roh, 2000 [37]

Selection Comparability Outcome

Representativeness of Selection of the Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
the exposed cohort non-exposed cohort of exposure outcome of interest cohorts on the of outcome long enough for up of cohorts
was not present at basis of the design outcomes to
start of study (for or analysis occur
contracture)

(a) Truly representative of the (a) Drawn from the (a) Secure record (e.g. (a) Yes$ (a) Most important (a) Independent blind (a) Yes (at least (a) Complete follow
average children with burns same community as clinical records)$ factors of adjustment assessment $ 6 months) $ up – all subjects

burns 41 (2015) 890–906

to the volar aspect of the the exposed cohort$ (b) No $ (age, extent of the (b) Record linkage$ accounted for$
hands receiving SG in the (b) Structured burns, the use of (b) No NA
community $ (b) Drawn from a interview $ physiotherapy and (c) Self-report (for (b) Subjects lost to
different source splinting) side effects) follow up unlikely
(b) Somewhat representative (c) Written self to introduce bias
of the average children with (c) No description of report (b) Any additional (d) No description (lost to follow-up
burns to the volar aspect of the derivation of the factor $: (origins of 5%) $
the hands receiving SG in the non exposed cohort (d) No description SG, time of follow-up)
community $ (c) Subjects lost to
follow up >5%
(c) Selected group of children and description
with burns to the volar aspect provided of those
of the hands due to specific lost
causes e.g. chemical or
electrical injuries (d) No statement

(d) No description of the

derivation of the cohort

Selection: $$$$.
Comparability: 0.
Outcome: $$.

901
 902
Study (author and year): Jang, 2001 [36]

Selection Comparability Outcome

Representativeness of Selection of the non- Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
the exposed cohort exposed cohort of exposure outcome of interest cohorts on the of outcome long enough for up of cohorts
was not present at basis of the design outcomes to
start of study (for or analysis occur
contracture)

(a) Truly representative of (a) Drawn from the same (a) Secure record (a) Yes $ (a) Most important (a) Independent (a) Yes (at least (a) Complete follow
the average children with community as the (e.g. clinical factors of adjustment blind 6 months)$ up – all subjects

burns 41 (2015) 890–906

burns to the volar aspect exposed cohort $ records) $ (b) No $ (age, extent of the assessment $ accounted for $
of the hands receiving burns, the use of (b) No
SG in the community $ (b) Drawn from a different (b) Structured physiotherapy and (b) Record (b) Subjects lost to
source interview $ splinting) linkage $ follow up unlikely
(b) Somewhat representative to introduce bias
of the average children with (c) No description of the (c) Written self (b) Any additional (c) Self-report (lost to follow-up
burns to the volar aspect derivation of the non report factor $: (origins (for side 5%) $
of the hands receiving SG exposed cohort of SG, time effects)
in the community $ (d) No description of follow-up) (c) Subjects lost to
(d) No follow up >5% and
(c) Selected group of children description description provided
with burns to the volar of those lost
aspect of the hands due to
specific causes e.g. chemical (d) No statement
or electrical injuries.

(d) No description of the

derivation of the cohort

Selection: $.
Comparability: 0.
Outcome: $.
 Study (author and year): Al-Qattan, 2009 [35]

Selection Comparability Outcome

Representativeness of Selection of the non- Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
the exposed cohort exposed cohort of exposure outcome of interest cohorts on the of outcome long enough for up of cohorts
was not present at start basis of the design outcomes to
of study (for contracture) or analysis occur

(a) Truly representative of (a) Drawn from the same (a) Secure record (a) Yes $ (a) Most important (a) Independent (a) Yes (at least (a) Complete follow
the average children with community as the (e.g. clinical (b) No factors of adjustment blind 6 months)$ up – all subjects

burns 41 (2015) 890–906

burns to the volar aspect of exposed cohort $ records) $ $ (age, extent of the assessment $ accounted for $
the hands receiving SG in burns, the use of (b) Record (b) No
the community $ (b) Drawn from a (b) Structured physiotherapy and linkage $ (b) Subjects lost to
different source interview $ splinting) follow up unlikely
(b) Somewhat representative (c) Self-report to introduce bias
of the average children with (c) No description of (c) Written self (b) Any additional (for side effects) (lost to follow-up
burns to the volar aspect of the derivation of the report factor $: (origins of  5%) $
the hands receiving SG in the non exposed cohort SG, time of follow-up) (d) No description
community $ (d) No description (c) Subjects lost to
follow up > 5%
(c) Selected group of children and description
with burns to the volar aspect provided of those
of the hands due to specific lost
causes e.g. chemical or
electrical injuries. (d) No statement

(d) No description of the

derivation of the cohort

Selection: $$.
Comparability: 0.
Outcome: $$.

903
 904
Study (author and year): Chandrasegaram, 2009 [34]

Selection Comparability Outcome

Representativeness of Selection of the non- Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
the exposed cohort exposed cohort of exposure outcome of interest cohorts on the of outcome long enough for up of cohorts
was not present at basis of the design outcomes to occur
start of study (for or analysis
contracture)

(a) Truly representative of the (a) Drawn from the same (a) Secure record (a) Yes$ (a) Most important (a) Independent (a) Yes (at least (a) Complete follow

burns 41 (2015) 890–906

average children with burns community as the (e.g. clinical (b) No factors of adjustment blind 6 months) $ up – all subjects
to the volar aspect of the exposed cohort $ records)$ $ (age, extent of the assessment $ accounted for $
hands receiving SG in the burns, the use of (b) Record (b) No NA
community $ (b) Drawn from a (b) Structured physiotherapy and linkage$ (b) Subjects lost to
different source interview $ splinting) follow up unlikely
(b) Somewhat representative (c) Self-report to introduce bias
of the average children with (c) No description of the (c) Written self (b) Any additional (for side effects) (lost to follow-up
burns to the volar aspect of derivation of the non report d) no factor $: (origins of 5%) $
the hands receiving SG in the exposed cohort description SG, time of follow-up) (d) No description
community $ (c) Subjects lost to
follow up >5% and
(c) Selected group of children description provided
with burns to the volar aspect of those lost
of the hands due to specific
causes e.g. chemical or (d) No statement
electrical injuries.
d) no description of the
derivation of the cohort

Selection: $$$$.
Comparability: 0.
Outcome: $$.
 Study (author and year): Chan, 2013 [11]

Selection Comparability Outcome

Representativeness of Selection of the non- Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
the exposed cohort exposed cohort of exposure outcome of interest cohorts on the of outcome long enough up of cohorts
was not present at basis of the design for outcomes
start of study or analysis to occur
(for contracture)

(a) Truly representative of the (a) Drawn from the same (a) Secure record (a) Yes$ (a) Most important (a) Independent (a) Yes (at least (a) Complete follow
average children with burns community as the (e.g. clinical factors of adjustment blind assessment$ 6 months)$ up – all subjects

burns 41 (2015) 890–906

to the volar aspect of the exposed cohort $ records) $ (b) No $ (age, extent of the accounted for$
hands receiving SG in the burns, the use of (b) Record linkage $ (b) No
community $ (b) Drawn from a (b) Structured physiotherapy and (b) Subjects lost to
different source interview$ splinting) (c) Self-report (for follow up unlikely
(b) Somewhat representative side effects) to introduce bias
of the average children with (c) No description of the (c) Written self (b) Any additional (lost to follow-up
burns to the volar aspect of derivation of the non report factor $: (origins of (d) No description  5%) $
the hands receiving SG in the exposed cohort SG, time of follow-up)
community $ (d) No description (c) Subjects lost to
follow up > 5%
(c) Selected group of children and description
with burns to the volar aspect provided of those
of the hands due to specific lost
causes e.g. chemical or
electrical injuries. (d) No statement

(d) No description of the

derivation of the cohort

Selection: $$$$.
Comparability: 0.
Outcome: $$$.

905
906 burns 41 (2015) 890–906

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