• Mallet fracture A = distal phalanx physeal injury (pediatrics)B = fracture fragment involving 20% to 50% of articular surface (adult)C = fracture fragment >50% of articular surface (adult)
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A 42-year-old sustains a left finger injury while attempting to catch a baseball for his son. He presents with left, long finger pain and an inability to extend his middle finger at the distal interphalangeal joint. A radiograph after closed reduction and splinting is shown in Figure A. What is the best course of treatment?
Reduction and pinning
Repeat splinting of the distal interphalangeal joint in extension
Splinting of the distal and proximal interphalangeal joints in extension
Fusion of the distal interphalangeal joint
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The radiograph depicts a bony mallet injury with volar subluxation of the distal phalanx after splinting of the DIP joint in extension, which is an indication for reduction and pinning.
A mallet deformity is caused by disruption of the terminal extensor tendon distal to DIP joint. Occasionally, a bony avulsion of the distal phalanx is noted on radiographs. "Bony" mallet fingers will rarely require surgical fixation. It is important to attempt to splint a bony mallet injury and get a new radiograph prior to making the decision for operative treatment. Indications for surgical management of this condition include volar subluxation of the distal phalanx even after DIP splinting.
Stern et al. found a higher long-term complication rate with surgical treatment of mallet injuries. He also noted 15 degrees more DIP flexion at follow-up in the splinting group compared to the surgical group.
Pegoli et al. describe an extension block technique for treatment of this injury with good results. Their indications for surgery included the presence of a large bone fragment, and palmar subluxation or the loss of joint congruity of the distal interphalangeal joint.
Theivendran et al. review the surgical treatment of DIP joint fractures and state that 30% articular involvement is an indication for operative treatment.
Figure A shows a lateral radiograph with a large intra-articular bony avulsion fragment and volar subluxation of the distal phalanx.
Answer 2,3,4: This patient meets the indications for ORIF and nonoperative modalities would not be appropriate.
Answer 5: A DIP fusion in a young patient would not be appropriate.
Pegoli L, Toh S, Arai K, Fukuda A, Nishikawa S, Vallejo IG
J Hand Surg Br. 2003 Feb;28(1):15-7. PMID: 12531661 (Link to Abstract)
Pegoli, JHS 2003
Theivendran K, Singh T, Rajaratnam V
Acta Orthop Belg. 2010 Aug;76(4):425-31. PMID: 20973346 (Link to Abstract)
Theivendran, ACTAB 2010
Stern PJ, Kastrup JJ.
J Hand Surg Am. 1988 May;13(3):329-34. PMID: 3379263 (Link to Abstract)
Stern, JHS 1988
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Average 4.0 of 18 Ratings
A 27-year-old male presents with finger pain 2 days after suffering an injury while playing basketball. Physical exam shows swelling of the distal interphalangeal joint with no evidence of open injury. A radiograph is shown in Figure A. Which of the following is the most appropriate treatment at this time?
Extension splinting of DIP joint for 6-8 weeks
Closed reduction and percutaneous pinning
Open reduction and internal fixation
Swan neck deformity correction
The clinical presentation is consistent with a non-displaced bony mallet finger without joint subluxation. Extension splinting of the DIP joint for 6-8 weeks is the most appropriate treatment.
A mallet finger is a deformity caused by disruption of the terminal extensor tendon distal to DIP joint. Treatment is dictated by the degree of displacement and acuity of injury. Acute injuries with minimal displacement and no joint subluxation are treated with extension bracing for 6-8 weeks. ORIF or closed reduction and percutaneous fixation is indicated for chronic injuries or acute injuries with volar displacement of the distal phalanx, a >2mm articular step-off, or when a majority (>50%) of the articular surface is involved.
Pegoli et al. report the results of extension block Kirschner wire fixation for the treatment of mallet fractures of the distal phalanx in 65 consecutive patients. Their results showed 46% excellent, 32% good, 20% fair and 2% poor results. The recommend the following indications for operative treatment: presence of a large bone fragment, palmar subluxation, or the loss of joint congruity of the distal interphalangeal joint.
Theivendran et al. report operative fixation is indicated when more than 30% of the articular surface is involved with or without subluxation of the joint. They summarize the management options for intra-articular distal interphalangeal fractures, placing particular emphasis on surgical treatment.
Figure A shows a non-displaced bony mallet Injury. Illustration A shows an example of an extension splint used for non-operative management of mallet injuries. Illustration V is a video showing the surgical technique for a Mallet finger.
Answer 2: Closed reduction and percutaneous pinning is indicated for a displaced mallet finger injury with joint subluxation.
Answer 3: Open reduction and internal fixation is indicated for displaced, subluxed mallet finger injuries that can not be reduced closed.
Answer 4: DIP arthrodesis is indicated in patients with a painful, stiff, arthritic DIP joint.
Answer 5: Swan neck deformity correction is indicated for a chronic mallet finger that has led to a swan neck deformity.
Average 4.0 of 14 Ratings
This video shows an ORIF of a bony mallet thumb using a Goal Post flap.
HPI - A week ago playing basketball axial loading trauma to the fourth digit of the dominant hand.
How would you treat this injury?