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
Burn is one of the most common cases in plastic surgery
which has various and prolonged sequelae especially in
children. It is the fifth most common cause of non-fatal
injuries in childhood [1]. Worldwide, it is estimated that
over half a million children are hospitalized with burns
every year [2]. In low- and middle-income countries,
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
naturally they are active and curious to explore their
surroundings with their hands but they have slow with-
drawal reflexes which cause them to have prolonged
contact with heat sources resulting in a deeper burn [3–5].
Burns in children mostly are caused by scald from hot
liquids, flame, and direct contact with hot objects in which
the latter can cause deep burns to the palms [6,7].
Most of superficial pediatric hand burns can be treated
with topical antibiotics, dressing, and splinting, however, in
cases of deep partial and full thickness burns, surgical
interventions are needed to close the wound [4,8,9].
Modalities available to cover deep palmar hand burns are
skin grafts and flaps. Surgeons utilize skin grafts more often
than flaps because the cases of pediatric burned hand which
need flaps to cover the wound are rare. However, the nature
of skin grafts is to develop secondary contracture [7]. It is
aggravated by the nature of the hand to flex in resting
position (intrinsic minus posture) due to relatively greater
strength of the flexor musculature [5,10]. This flexion
contracture is undesirable since it will give long-term
impacts toward children’s hand function and psychosocial
well-being [11].
Several methods have been applied to immobilize the
hands and prevent the formation of flexion contracture
such as splinting, exercising, and pressure garments [7,8].
During rehabilitation period, the hand is splinted in position
of extended wrist and hyperextended metacarpophalangeal
(MP) and interphalangeal (IP) joints of digits 2–5 to maintain
antideformity position [12]. Unfortunately, it is difficult to
get cooperation from children to comply to the regimen
therefore some degrees of contracture will still develop [10].
The use of either split-thickness (STSG) or full-thickness
skin grafts (FTSG) as a wound closure has its own benefits and
drawbacks. Controversy regarding which type of skin grafts is
better to achieve good functional and esthetic outcomes in
pediatric palmar hand burns is still present [11]. Based on our
clinical experiences, the use of FTSG will still result in the
night splint use. The aim of this systematic review is therefore
to investigate studies comparing STSG and FTSG use to
resurface the fingers and palm burns in pediatric hands in
terms of functional outcomes and esthetic appearances. We
considered conducting this systematic review because we try
to provide a higher level of evidence, comparing FTSG and
STSG, since most of the available studies do not exceed level
III evidence.
2. Methods
The systematic review method was made based on the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines (www.prisma-statement.org)
[13].
2.1. Search and selection processes
Studies comparing the use of FTSG and STSG for covering
burns of the volar aspects of the hand in children were our
main interest. Papers reporting hand injuries inflicted by
causes other than burns and burns to the dorsum of the
hand were excluded. We also excluded studies which
discussed flaps and the use of either FTSG or STSG alone,
case reports/series, narrative review, letter to editor, and
articles without available full-text. The assessed outcomes
were in the form of functional outcomes including range of
motion (ROM), incidence of contracture/re-contracture, and
esthetic outcomes.
PubMed and the Cochrane Library search were conducted
in February 2014. The publication date was limited from 1st
January 1980 until 31st December 2013. Only articles published
in English were included in this study. A specific search term
(in Appendix) was developed using keywords ‘‘hand injuries’’,
‘‘contracture’’, and ‘‘skin transplantation’’ so that no relevant
study was missed. The title and abstract of retrieved articles
were screened by applying inclusion and exclusion criteria
and full-text of relevant articles were obtained. Furthermore,
the reference list from each relevant study was also screened
for potentially suitable studies. Each included study was
scrutinized by three reviewers (TOHP, PMS, and DKAS) and
difference in opinion was settled through consensus. (Fig. 1)
2.2. Data extraction and quality assessment
A data extraction table was created to extract data from
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-
erative therapy, and outcome measures from all included
studies.
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
of skin grafts, and time of follow-up. Methods of postoperative
therapy were defined as any treatments performed after the
skin grafting especially physiotherapy and splinting. Outcome
measures were defined as any measurements used to assess
the outcomes after the skin grafting.
We used the Newcastle–Ottawa Scale (NOS)[14] for asses-
sing the quality of the included studies in this systematic
review. There are three major components of this scale,
namely selection of the groups of study, comparability, and
assessment of the outcome.
3. Results
From PubMed and Cochrane Library searches, there were a
total of 663 articles retrieved. After applying inclusion and
exclusion criteria to the title and abstract, 28 articles were
selected. Eighteen articles [8,10,15–30] which did not meet the
inclusion criteria and 2 articles [31,32] which did not have
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
articles was also conducted and 1 article[33] was found to be
suitable for this review; however, the full text cannot be
obtained. Finally, a total of 8 articles were included for review
in this paper [5,11,34–39] (Table 1).
The included studies consist of 1 prospective cohort study
[11] and 7 retrospective cohort studies [5,34–39]. Six articles
[5,11,34,36–38] discussed early excision and skin grafting and
2 articles [35,39] addressed contracture release and skin
grafting of pediatric palmar hand burns. Five studies
[5,11,34,35,38] applied splinting with various methods and 4
studies [5,11,34,38] applied physiotherapy as the post-opera-
tive management (Table 2). One study [36] did not use
splinting and 2 studies [37,39] did not explain about the
splinting and physiotherapy application. Objective outcome
measurements were used by 3 studies; 2 studies [38,39] used
ROM and 1 study [11] used Vancouver Scar Scale (VSS), while
the other studies used subjective measurements in the form
of incidence of contracture/re-contracture and received
secondary reconstructive procedures (Table 3).
Most of the causes of palmar hand burns are contact with
hot surfaces and they were mostly suffered by children aged
below 5 years old. Mean time from burns to skin grafts was
approximately 2–3 weeks. The source of FTSG was mostly
from the groin and STSG was from the thigh. Average time of
follow up is more than 6 months (Table 1).
Overall, there are 6 studies [5,34–38] which showed that the
hands in FTSG group had less contracture rate compared to
hands in STSG group. However, the study by Al-Qattan [35]
used a protocol in which STSG was used in more severe burn,
i.e. larger and deeper burns. Studies by Jang et al. [36], Roh et al.
[37], and Merrell et al. [5] did not apply statistical analysis. Two
studies [11,39] demonstrated no significant difference in
contracture rate between FTSG and STSG group (Table 3).
3.1. Outcome evaluation – ROM
ROM to evaluate the functional outcomes was used in 3
studies. Merrell et al. [5] classified the ROM qualitatively
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
of publication
Chan et al. (2013) [11]
Chandrasegaram
et al. (2009) [34]
Al-Qattan (2009) [35]
Jang et al. (2001) [36]
Roh et al. (2000) [37]
Schwanholt et al.
(1993) [38]
Pensler et al. (1988) [39]
Merrell et al. (1986) [5]
FTSG: full-thickness skin graft; NA: not available; ROM: range of motion; STSG: split-thickness skin graft.
Mean time from Origin of SG Physiotherapy and Mean time of
burns to SG splinting methods follow-up
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
3 weeks NA Maximal physiotherapy NA
and serial splinting
Contracture FTSG: groin Physiotherapy NA; night 6 months to 10 years
release STSG: thigh extension splint
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
FTSG: 14.8 days, FTSG: groin NA NA
STSG: 17.5 days STSG: scalp
or thigh
FTSG: 11.0  1.8 days FTSG: inguinal ROM exercises 5 days after FTSG: 23  2 months
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
Contracture release NA NA FTSG: 4.7  2.0 years
STSG: 6.0  3.2 years
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’’

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

3.2. Methodological quality of the included studies 4. Discussion

All studies involved truly and somewhat representative
exposed cohort of the average children with burns to the
volar aspect of the hands receiving skin grafts in the
community. All but one study [36] obtained the non-exposed
cohort from the same community as the exposed cohort.
All but 3 studies ascertained the exposure by secure
record (medical records), one by structured interview [11],
and two did not describe the method of ascertainment
[35,36]. No studies mentioned adjustment for any con-
founding factors.
The ideal management of pediatric hand burns is very
crucial for optimal functional and esthetic outcomes of the
hands of the fast-growing children; yet some of the issues
are still debatable. In this review, the option to use FTSG
or STSG for covering the volar aspect of hand burns in
children is discussed.
The current trend is to use FTSG as the wound coverage
for the pediatric hand burns because it is believed that it
has less secondary contracture rate and decreases the need
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
(1993) [38] ROM score (median)
Secondary reconstructive
surgical procedure
8/14 4/16 P = 0.078 – Improve function and decrease
0 1.5 P = 0.025 need for reconstructive
3/14 10/16 P = 0.028 procedures with FTSGs
– 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
Newcastle-Ottawa Scale (NOS).
Studies (Year) Components
Selection Comparability Outcome
Merrell et al. (1986) $$$$ 0 $$$
[5]
Pensler et al. (1988) $$$ 0 $$$
[39]
Schwanholt $$$$ 0 $$$
et al. (1993)[38]
Roh et al. (2000)[37] $$$$ 0 $$
Jang et al. (2001)[36] $ 0 $ splints and physiotherapy to the patients but one study [36]
Al-Qattan (2009)[35] $$ 0 $$
Chandrasegaram $$$$ 0 $$
et al. (2009) [34]
Chan et al. (2013) $$$$ 0 $$$
[11]
possesses some limitations in its use. FTSG has limited donor
sources; therefore it cannot be used to cover large surface area
of burns. It also has a lower take rate compared to STSG
because of edema and inflammation reactions. Furthermore,
the wound that is covered with FTSG will be more hairy
because it also includes the hair follicles. STSG also owns some
drawbacks such as a higher rate of secondary contracture and
relatively less esthetic value. However, the use of STSG is
advantageous in the sense that it can cover large area and has
a good take rate. The presence of infection will also affect the
survival of the graft especially in FTSG due to its lower graft
take rate [40]. Therefore, STSG may be more favorable,
particularly for burn patients in developing countries where
the risk of surgical site infection is high [41]. From the
experience of the first author, patients still suffered from
certain degree of secondary contracture regardless the type of
skin grafts utilized unless optimal physiotherapy and splint-
ing were applied diligently. However, the lack of compliance
from children made physiotherapy and splinting difficult to be
applied.
From the included studies, there is no agreement regarding
the best skin graft type to cover the pediatric volar hand burns.
Chan et al. [11] states that except for scar pliability, there was
no significant difference between FTSG and STSG in the
outcomes of deep palm burns in children. Chandrasegaram
et al. [34] supports the use of FTSG particularly in palmar burns
that extend into the digits. The study conducted by Al-Qattan
[35] is considered bias because the protocol was to use FTSG for
small wounds and STSG for large defects. The impacts of graft
types on the outcomes cannot be elucidated in Jang et al. [36],
Roh et al. [37], and Merrell et al. [5] studies because there were
no statistical analysis. Pensler et al. [39] encourages the use of
STSG while Schwanholt et al. [38] promotes the use of FTSG for
deep palm burns in pediatric patients. We can deduce from
those studies that the use of FTSG or STSG for pediatric volar
hand burns is influenced by several factors, namely surgeon’s
preference and experience; the depth and extent of the hand
burns; and also the location of the burns whether it involves
the web spaces and crosses the joints or not. The latter factor
is also supported by a study performed by Park et al. [15] which
concluded that primary FTSG is recommended for volar finger
reconstruction excluding web spaces regardless the number of
injured fingers. On the other hand, the use of STSG is
considered in burns affecting more than two fingers that
include the web spaces. In addition, the outcomes of pediatric
hand burns are also affected by the application of physiother-
apy/exercise and splinting.
Postoperative therapy in the forms of physiotherapy/
exercise and splinting is recommended to be integrated in
the management of pediatric volar hand burns even though
its success depends on the patient’s and family’s compli-
ance. In this review, 3 studies [5,11,38] applied extension
deliberately did not implement any physical therapy or
splinting method. It is reasoned that patients in the age
group younger than 12 months old were uncooperative and
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-
dren did not fully extend their fingers. We recommend the
use of ‘‘sandwich’’ splinting [5] with additional pads inside
that follow the contour of the fingers to not only keep them
in full extension position but also prevent the occurrence of
pressure sores and pain. We also perform physiotherapy in
the form of purposeful activity based on playing or play
therapy for the children. It is a very useful strategy to attract
the interest of children and break down barriers between the
child and therapist. Most importantly it can be used to
promote active hand movements. A study performed by
Omar et al. supports the use of purposeful activity based on
playing in the rehabilitation of children with hand burn
because it is more effective to reduce pain and improve hand
functions compared to rote exercise [42].
The quality of the studies discussed in this review is not
ideal. The included studies were few in number and lack
in quality. They are mostly retrospective cohort study with
small sample size. The heterogeneity of study populations
and outcomes also hinder comparisons. Almost all studies
lacked a standardized objective measurement to analyze
the outcomes. The rate of contracture/re-contracture and
secondary reconstructive procedure are mostly used as
the outcome measures. They are considered subjective
because they were based on the opinion of the evaluator(s)
and sometimes it was influenced by the improvement of
functional outcomes of the patients after the surgery. Some
examples of standardized objective tests to evaluate the
hand are total active motion (TAM) and total passive motion
using standard dorsal goniometer to measure ROM. There is
also missing information in some of the studies such as
the number of subjects [36], performed additional therapies
[37,39], the number of operating surgeon(s), and the number
of outcome assessor(s) [5,34–39]. This systematic review is
also subjected to bias because only English and published
studies included.
Based on this systematic review, currently there is no
strong, high-quality evidence to prove that FTSG is superior
to STSG to cover pediatric palmar burns. The current
practice that FTSG is better than STSG to resurface burned
volar hand in children cannot be justified. Either FTSG or
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
of the average children
with burns to the volar
aspect of the hands
receiving SG in the
community $
(b) Somewhat
representative of the
average children with
burns to the volar
aspect of the hands
receiving SG in the
community $
(a) Drawn from (a) Secure record (a) Yes$ (a) Most important (a) Independent (a) Yes (at least (a) Complete follow
the same (e.g. clinical records)$ factors of adjustment $ blind assessment $ 6 months)$ up – all subjects
community as (b) No (age, extent of the accounted for$
the exposed (b) Structured burns, the use of (b) Record linkage$ (b) No
cohort$ interview $ physiotherapy (b) Subjects lost to
and splinting) (c) Self-report (for follow up unlikely
(b) Drawn from (c) Written self side effects) to introduce bias
a different source report (b) Any additional (lost to follow-
factor $: (origins of (d) No description up 5%) $
(c) No description of (d) No SG, time of follow-up)
the derivation of the description (c) Subjects lost to
non exposed cohort follow up >5% and
description provided
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
of the hands receiving SG
in the community$
(b) Somewhat representative
of the average children with
burns 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
the exposed cohort $ records)$ (b) No (age, extent of the burns, (b) Record linkage$ accounted for $
the use of physiotherapy (b) No
(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) Any additional factor to introduce bias
(c) No description of (c) Written self $: (origins of SG, time (d) No description (lost to follow-up
the derivation of the report of follow-up) 5%) $
non exposed cohort
(d) No description (c) Subjects lost to
follow up >5% and
description provided
of those lost
(d) No statement

(d) No description of the

derivation of the cohort

Selection: $$$$.
Comparability: 0.
Outcome: $$$.

Representativeness of
the exposed cohort
(a) Truly representative of the
average children with burns
to the volar aspect of the
hands receiving SG in the
community $
(b) Somewhat representative
of the average children with
burns 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: $$$$.
Comparability: 0.
Outcome: $$.
Study (author and year): Roh, 2000 [37]
Selection Comparability Outcome
Selection of the Ascertainment Demonstration that Comparability of Assessment Was follow-up Adequacy of follow
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) Drawn from the (a) Secure record (e.g. (a) Yes$ (a) Most important (a) Independent blind (a) Yes (at least (a) Complete follow
same community as clinical records)$ factors of adjustment assessment $ 6 months) $ up – all subjects
burns 41 (2015) 890–906
the exposed cohort$ (b) No $ (age, extent of the (b) Record linkage$ accounted for$
(b) Structured burns, the use of (b) No NA
(b) Drawn from a interview $ physiotherapy and (c) Self-report (for (b) Subjects lost to
different source splinting) side effects) follow up unlikely
(c) Written self to introduce bias
(c) No description of report (b) Any additional (d) No description (lost to follow-up
the derivation of the factor $: (origins of 5%) $
non exposed cohort (d) No description SG, time of follow-up)
(c) Subjects lost to
follow up >5%
and description
provided of those
lost
(d) No statement
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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