Fist position for skin grafting on the dorsal hand: I. Analysis of length of the dorsal hand surgery in hand positions.

In skin grafting for reconstruction of burns and contracture deformities of the dorsal hand, the hand is kept in a proper position to provide the greatest amount of skin and to avoid the secondary functional deformity. The safe position has been commonly used for immobilizing the hand, but this is to protect the hand function rather than to provide maximal surface for skin grafting. Split-thickness skin graft contracts up to 30 to 50 percent of the original size owing to secondary contraction. If insufficient skin is grafted, contracture deformity of the dorsal hand may occur. To graft the greatest amount of skin on the dorsal hand, the hand should be kept preoperatively in a position flexing all joints of the wrist, metacarpophalangeal joints, and interphalangeal joints and maximally stretching the dorsal hand (a fist position). We studied the surface length of the dorsal hand between the wrist, the metacarpophalangeal joint, and the eponychium in the anatomic, safe, and fist positions of the right hand in 60 adults. Difference of total length between the anatomic and safe positions was not statistically significant (p > 0.05). The total length in a fist position was significantly increased in comparison with the other two positions (p < 0.05). In a fist position compared with the safe position, the increase in length of the dorsal surface of the proximal hand was 11 to 20 percent except in the thumb, and the increase in length of the dorsal surface of the finger was 12 to 17 percent. The increase in total length of a fist position was about 9 mm (7 to 8 percent) in the thumb and 20 to 32 mm (14 to 18 percent) in the index to little fingers. It suggests that the safe position fails to provide an increased dorsal hand surface area for skin grafting compared with the anatomic position. The greatest amount of skin can be grafted in a fist position. Hand immobilization in a fist position for 7 to 9 days after skin grafting has not resulted in irrevocable joint stiffness in our experience. If injury of the deep structures is not present, the hand should be immobilized in a fist position before skin grafting on the dorsal hand.