Updated: 10/4/2016

Mallet Finger

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Questions
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Evidence
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Videos
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https://upload.orthobullets.com/topic/6014/images/Xray - lateral_moved.jpg
https://upload.orthobullets.com/topic/6014/images/mallet.jpg
https://upload.orthobullets.com/topic/6014/images/Splints_moved.jpg
https://upload.orthobullets.com/topic/6014/images/A1_moved.jpg
Introduction
  • A finger deformity caused by disruption of the terminal extensor tendon distal to DIP joint
    • the disruption may be bony or tendinous
  • Epidemiology
    • risk factors
      • usually occur in the work environment or during participation in sports
    • demographics
      • common in young to middle-aged males and older females
    • body location
      • most frequently involves long, ring and small fingers of dominant hand
  • Pathophysiology
    • mechanism of injury
      • traumatic impaction blow
        • usually caused by a traumatic impaction blow (i.e. sudden forced flexion) to the tip of the finger in the extended position.
        • forces the DIP joint into forced flexion
      • dorsal laceration
        • a less common mechanism of injury is a sharp or crushing-type laceration to the dorsal DIP joint
Classification
  • Doyle's Classification 
Doyle's Classification of Mallet Finger Injuries
Type I
 • Closed injury with or without small dorsal avulusion fracture
Type II
 • Open injury (laceration)
Type III
 • Open injury (deep soft tissue abrasion involving loss skin and tendon substance)
Type IV

 • 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)


Presentation
  • Symptoms
    • primary symptoms
      • painful and swollen DIP joint following impaction injury to finger 
        •  often in ball sports
  • Physical exam
    • inspection
      • fingertip rest at ~45° of flexion
    • motion
      • lack of active DIP extension
Imaging
  • Radiographs
    • findings
      • usually see bony avulsion of distal phalanx 
      • may be a ligamentous injury with normal bony anatomy
Treatment
  • Nonoperative
    • extension splinting of DIP joint for 6-8 weeks 
      • indications
        • acute soft tissue injury (< than 12 weeks)
        • nondisplaced bony mallet injury
      • technique
        • maintain free movement of the PIP joint  
        • worn for 6-8 weeks
        • volar splinting has less complications than dorsal splinting
        • avoid hyperextension
        • begin progressive flexion exercises at 6 weeks
  • Operative 
    • CRPP vs ORIF post
      • indications
        • absolute indications 
          • volar subluxation of distal phalanx
        • relative indications
          • >50% of articular surface involved
          • >2mm articular gap
    • surgical reconstruction of terminal tendon
      • indications
        • chronic injury (> 12 weeks) with healthy joint
      • outcomes
        • tendon reconstruction has a high complication rate (~ 50%)
    • DIP arthrodesis
      • indications
        • painful, stiff, arthritic DIP joint
    • Swan neck deformity correction
      • indications
        • Swan neck deformity present
Techniques
  • CRPP vs ORIF
    • approach
      • dorsal midline incision
    • fixation
      • simple pin fixation
      • dorsal blocking pin 
  • Surgical reconstruction of terminal tendon
    • repair
      • this may be done with direct repair/tendon advancement, tenodermodesis, or spiral oblique retinacular ligament reconstruction
  • Swan neck deformity correction
    • techniques to correct Swan neck deformity include
      • lateral band tenodesis
      • FDS tenodesis
      • Fowler central slip tenotomy
        • for deformities of <35° extensor lag
      • minimal Swan Neck deformities may correct with treatment of the DIP pathology alone
Complications
  • Extensor lag
    • a slight residual extensor lag of < 10° may be present at completion of closed treatment
  • Swan neck deformities  
    • occurs due to
      • attenuation of volar plate and transverse retinacular ligament at PIP joint
      • dorsal subluxation of lateral bands
      • resulting PIP hyperextension
      • contracture of triangular ligament maintains deformity
 

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Questions (4)
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(OBQ12.2) 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? Review Topic

QID: 4362
FIGURES:
1

Reduction and pinning

89%

(4805/5380)

2

Repeat splinting of the distal interphalangeal joint in extension

5%

(295/5380)

3

Splinting of the distal and proximal interphalangeal joints in extension

3%

(174/5380)

4

Observation

1%

(34/5380)

5

Fusion of the distal interphalangeal joint

0%

(14/5380)

ML 1

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PREFERRED RESPONSE 1

(OBQ12.85) 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? Review Topic

QID: 4445
FIGURES:
1

Extension splinting of DIP joint for 6-8 weeks

91%

(4620/5083)

2

Closed reduction and percutaneous pinning

6%

(325/5083)

3

Open reduction and internal fixation

2%

(85/5083)

4

DIP arthrodesis

0%

(14/5083)

5

Swan neck deformity correction

0%

(5/5083)

ML 1

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PREFERRED RESPONSE 1
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ARTICLES (13)
VIDEOS (1)
CASES (1)
Topic COMMENTS (13)
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