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Mallet Finger

Abstract
Mallet finger involves loss of continuity of the extensor tendon
over the distal interphalangeal joint. This common hand injury
results in a flexion deformity of the distal finger joint and may lead
to an imbalance between flexion and extension forces more
proximally in the digit. Mallet injuries can be classified into four
types, based on skin integrity and the presence or absence of bony
involvement. Although various treatment protocols have been
proposed, splinting of the distal interphalangeal joint for 6 to 8
weeks has yielded good results while minimizing morbidity in the
majority of patients. Surgical management may be considered for
acute and chronic mallet lesions in patients who have failed
nonsurgical treatment, are unable to work with the splint in
position, or have a fracture involving more than one third of the
joint surface.
F
ingertip injuries are among the
most common traumatic prob-
lems encountered by hand surgeons.
One such injury, which involves dis-
ruption of the extensor mechanism
at the level of the distal interpha-
langeal (DIP) joint, is commonly re-
ferred to as a mallet, baseball, or
drop finger.
1,2
The termmallet finger
originated during the late nineteenth
century, in reference to a frequently
seen sports-related flexion deformi-
ty of the fingertip.
3
The injury is
now known to occur in association
with any activity leading to forced
flexion of the DIP joint.
Recognition and diagnosis of a
mallet finger are relatively straight-
forward. Treatment requires careful
attention to detail by the surgeon
and diligent patient compliance to
restore function and avoid complica-
tions. Knowledge of the complex
anatomy of the extensor mechanism
of the finger is essential, as is a thor-
ough understanding of howa disrup-
tion at the DIP joint level can upset
the delicate balance of extension and
flexion forces more proximally. Al-
though most mallet injuries can be
successfully managed nonsurgically,
surgery is occasionally recommend-
ed for treatment of either an acute or
a chronic mallet finger or for salvage
of failed prior treatment.
Epidemiology
Mallet finger injuries usually occur
in the work environment or during
sports participation.
2
The most fre-
quently involved digits are the long,
ring, and small fingers of the domi-
nant hand.
1
The lesion is often seen
in young to middle-aged males;
women with this injury tend to be
older. Although most mallet fingers
are caused by a traumatic event,
Jones and Peterson
4
found an unusu-
ally high incidence in a three-
generation family, with 85% of the
lesions developing spontaneously or
after minimal trauma. The authors
proposed a possible genetic predispo-
sition toward mallet finger deformi-
ty in certain individuals.
Anup A. Bendre, MD,
Brian J. Hartigan, MD, and
David M. Kalainov, MD
Dr. Bendre is Orthopaedic Surgeon,
OAD Orthopaedics, Warrenville, IL.
Dr. Hartigan is Assistant Professor of
Clinical Orthopaedic Surgery,
Department of Orthopaedic Surgery,
Northwestern University, Feinberg
School of Medicine, Northwestern
Center for Orthopedics, Chicago, IL.
Dr. Kalainov is Assistant Professor of
Clinical Orthopaedic Surgery,
Department of Orthopaedic Surgery,
Northwestern University, Feinberg
School of Medicine, Northwestern
Center for Orthopedics.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Bendre, Dr. Hartigan, and Dr.
Kalainov.
Reprint requests: Dr. Bendre, OAD
Orthopaedics, 27650 Ferry Road,
Warrenville, IL 60555-3845.
J Am Acad Orthop Surg 2005;13:336-
344
Copyright 2005 by the American
Academy of Orthopaedic Surgeons.
336 Journal of the American Academy of Orthopaedic Surgeons
Anatomy
The anatomy of the extensor ten-
don of the finger has been well
described
1,2,5-7
(Fig. 1). The extrinsic
extensor tendon originates in the
forearm and courses over the finger
metacarpophalangeal (MCP) joint.
The extrinsic extensor tendon has an
indirect attachment to the proximal
phalanx, such that the primary ex-
tensor force across the MCP joint is
transmitted through the sagittal
band connections to the volar plate.
The extrinsic tendon continues dis-
tally and trifurcates over the proxi-
mal phalanx. The central continua-
tion of the extensor tendon (ie, the
central slip) attaches to the dorsal
base of the middle phalanx, exerting
an extensor force across the proxi-
mal interphalangeal (PIP) joint.
The interosseous and lumbrical
muscles provide the intrinsic contri-
bution to the extensor mechanism.
These muscle-tendon units form a
lateral band on each side of the dig-
it, passing volar to the MCP joint.
The lateral bands join with the later-
al slips of the extrinsic extensor ten-
don at the level of the PIP joint to
form the conjoined lateral bands.
The two conjoined lateral bands
then converge dorsally and insert at
the base of the distal phalanx as the
terminal extensor tendon.
The other components of the ex-
tensor apparatus stabilize the exten-
sor hood and coordinate joint move-
ment. The triangular ligament is a
thin tissue connecting the conjoined
lateral bands over the middle pha-
lanx. This structure prevents separa-
tion and volar migration of the later-
al bands when the PIP joint is flexed.
The transverse retinacular ligaments
originate from each side of the PIP
joint volar plate, inserting dorsally
into the adjacent conjoined lateral
band. These ligaments stabilize and
limit dorsal migration of the lateral
bands during PIP joint extension.
The oblique retinacular ligaments
arise from the flexor tendon sheath
and volar aspect of the proximal pha-
lanx. They course distally to insert
onto the dorsal base of the distal
phalanx with the terminal extensor
tendon, thus linking and coordinat-
ing PIP and DIP joint motion.
Mechanism of Injury
and Pathoanatomy
Mallet finger most commonly is
caused by sudden forced flexion of
the extended fingertip, resulting in
either stretching or tearing of the ex-
tensor tendon substance or avulsion
of the tendon insertion fromthe dor-
sum of the distal phalanx, with or
without a fragment of bone. Open
injuries are caused by a laceration,
crush, or deep abrasion. A less fre-
quent mechanism of injury involves
Figure 1
Finger extensor mechanism anatomy. A, Lateral view. B, Dorsal view. DIP = distal interphalangeal joint, MCP = metacarpopha-
langeal joint, ORL = oblique retinacular ligament, PIP = proximal interphalangeal joint, TRL = transverse retinacular ligament.
(Adapted with permission from Coons MS, Green SM: Boutonniere deformity. Hand Clin 1995;11:387-402.)
Anup A. Bendre, MD, et al
Volume 13, Number 5, September 2005 337
forced hyperextension of the DIP
joint with a resultant fracture at the
dorsal base of the distal phalanx.
2
The functional anatomy of the
finger represents a well-balanced
systembetween intrinsic and extrin-
sic tendons, and between flexion and
extension forces across each finger
interphalangeal (IP) joint. Kaplan
5
recognized that any injury causing a
flexion or extension deformity in
one IP joint can lead to tendon im-
balance, creating an opposite defor-
mity in the adjacent IP joint (Fig. 2).
At the DIP joint, the flexor digi-
torum profundus flexion force is
counterbalanced by the terminal ex-
tensor tendon. At the level of the PIP
joint, the flexion forces of the flexor
digitorum profundus and superficia-
lis tendons are counterbalanced by
the extension forces of the conjoined
lateral bands and the central slip of
the extensor apparatus.
With a mallet injury, the delicate
balance between flexion and exten-
sion forces is disrupted. The discon-
tinuity of the terminal extensor ten-
don allows the extensor apparatus to
migrate proximally, thus increasing
extensor tone at the PIP joint rela-
tive to the DIP joint. The resulting
imbalance can lead to an early or late
swan neck deformity (hyperexten-
sion of the PIP joint with concomi-
tant flexion of the DIP joint).
Classification
Acute mallet deformities have been
arbitrarily defined as those occurring
within 4 weeks of injury; chronic de-
formities are those presenting later
than 4 weeks frominjury.
8,9
The clas-
sification scheme developed by
Doyle
2
divides mallet injuries into
four types (Table 1). Type I lesions in-
volve closed trauma to the fingertip,
withor without a small avulsionfrac-
ture at the dorsal base of the distal
phalanx, resulting in loss of terminal
extensor tendon continuity. Type II
injuries are open tendon injuries
caused by laceration at or around the
DIP joint. Type III lesions are also
open injuries; they occur froma deep
soft-tissue abrasion with loss of skin
and tendonsubstance. Type IVlesions
present as mallet fractures and are
subclassified into three types. Type
IVAlesions are distal phalanx physeal
injuries in children. Type IVB lesions
are distal phalanx fractures in adults
involving 20% to 50% of the joint
surface. Type IVCinjuries are caused
by hyperextension, resulting ina frac-
ture fragment measuring >50%of the
distal phalanx articular surface; they
are associated with DIP joint volar
subluxation. This subclassificationof
mallet fractures corresponds to the
categorization scheme proposed by
Damron and Engber.
10
Wehb and
Schneider
11
developed their own clas-
sification systemfor type IVinjuries
based on fracture size and presence or
absence of DIP joint subluxation.
Clinical Evaluation
Diagnosis of a mallet finger is
relatively uncomplicated. Patients
present with pain, deformity, and/or
difficulty using the affected finger.
1
Posteroanterior, oblique, and lateral
radiographs of the digit are recom-
mended to assess for bone injury and
joint alignment. The examination
begins with an inspection of the soft
tissues as well as measurements of
finger MCP and PIP joint motion. In
acute injuries, tenderness is elicited
with palpation over the dorsal mar-
gin of the DIP joint. Although most
patients develop an extensor lag at
the DIP joint immediately after inju-
ry, the deformity may be delayed by
a few hours or even days. Concur-
rent hyperextension of the PIP joint
(ie, swan neck posture) may be not-
ed with active finger extension.
Management of Acute
Mallet Finger Injuries
Several options are available for
managing acute mallet finger inju-
Figure 2
Lateral view demonstrating the balance between flexion and extension forces at the
finger joints. The single dots represent the axes of flexion-extension at each joint.
The double dots represent the areas of action of the corresponding tendons at each
joint. (Adapted with permission from Kaplan EB: Anatomy, injuries and treatment
of the extensor apparatus of the hand and digits. Clin Orthop 1959;13:24-41.)
Doyles Classification of Mallet
Finger Injuries
2
Type Description
I Closed injury, with or without
small dorsal avulsion fracture
II Open injury (laceration)
III Open injury (deep abrasion
involving skin and tendon
substance)
IV Mallet fracture
A Distal phalanx physeal injury
(pediatric)
B Fracture fragment involving
20% to 50% of articular
surface (adult)
C Fracture fragment >50% of
articular surface (adult)
Table 1
Mallet Finger
338 Journal of the American Academy of Orthopaedic Surgeons
ries, including reassurance, observa-
tion, splint immobilization, and sur-
gery. Although there are no clearly
established criteria for an acceptable
result, Geyman et al
3
defined a satis-
factory outcome as one in which the
DIP joint exhibits a residual exten-
sor lag 20, the DIP flexion arc is
50, and the patient reports mini-
mal or no pain. Neglecting mallet in-
jury often results in permanent stiff-
ness and deformity at the DIP joint
level. Although many splint config-
urations and surgical techniques
have been described over the last
century, the optimal treatment of
each type of mallet finger injury re-
mains controversial.
Nonsurgical Management
Nonsurgical management has
been the standard of care for type I
mallet injuries as well as for closed
mallet fractures involving less than
one third of the articular surface
with no associated DIP joint sublux-
ation. However, differences of opin-
ion exist regarding both the style of
splint and the duration of immobili-
zation necessary to achieve an ac-
ceptable outcome.
Immobilization of both the PIP
and DIP joints was previously
thought to be necessary to relax the
extensor hood and intrinsic muscu-
lature during terminal extensor
tendon healing. Katzman et al
12
per-
formed a cadaveric study to deter-
mine whether PIP joint motion
would cause a tendon gap at the im-
mobilized DIP joint. They demon-
strated that gapping of a disrupted
terminal extensor tendon occurred
as a result of excursion of the distal
tendon stump during DIP joint flex-
ion, not because of retraction of the
proximal portion of the tendon with
simulated PIP joint extension. They
concluded that only the DIP joint
need be immobilized in extension to
allow healing of the mallet injury.
Most authors currently advocate
immobilization of the DIP joint
alone.
2,11,13
In the presence of a swan
neck deformity, however, Wehb and
Schneider
11
and Evans and Weight-
man
14
have suggested temporary in-
clusion of the PIP joint in flexion.
Combined PIP and DIP joint splint-
ing has not been conclusively proved
to restore tendon balance in a swan
neck deformity.
Splinting
Numerous splints have been de-
vised for managing mallet finger
injuries.
1-3
Common examples in-
clude the stack splint, the perforated
thermoplastic splint, and the alumi-
num foam splint (Fig. 3). Wilson and
Khoo
15
have reported their experi-
ence with a novel splint design,
which they termed the Mexican hat
splint. This splint incorporates a
buckle over the DIP joint to alle-
viate undue pressure on the healing
terminal extensor tendon. A steril-
ized aluminum splint secured with
sterile tape strips has been proposed
to treat mallet injuries in operating
room personnel.
16
Despite the many splints avail-
able, the principles of treatment re-
main constant. The involved digit is
immobilized in full extension or
slight hyperextension across the DIP
joint. Excessive extension should be
avoided because dorsal skin vascular
compromise can occur when the
joint is immobilized in more than
50% of the normal range for passive
DIP joint hyperextension.
15
Patients
are instructed on how to change the
splint for periodic cleaning and ex-
amination of the skin without al-
lowing the DIP joint to flex. Contin-
uous immobilization is maintained
for 6 to 8 weeks, followed by an ad-
ditional 2-week period of nighttime
splint use. A new full-length course
of immobilization is recommended
when the DIP joint is inadvertently
flexed during treatment. Frequent
physician assessment and patient
compliance are fundamental for suc-
cessful nonsurgical treatment.
Two recent studies have provided
information on the medium-termre-
sults of splint treatment of mallet in-
juries.
17,18
Okafor et al
17
used a stack
splint to treat 31 patients with either
a soft-tissue mallet injury or a mal-
let fracture. At 5-year follow-up, they
noted a 90%patient satisfaction rate,
with an average DIP joint extension
deficit of only 8.3. They concluded
that a small residual extensor lag and
radiographic evidence of DIP joint os-
Figure 3
Three different mallet finger splints. A, Stack splint (Stax Finger Splint, Sammons
Preston Rolyan, Bolingbrook, IL). B, Perforated thermoplastic splint (Aquaplast
Splinting Material, Sammons Preston Rolyan). C, Aluminum foam splint.
Anup A. Bendre, MD, et al
Volume 13, Number 5, September 2005 339
teoarthritis did not preclude a suc-
cessful treatment result. Foucher et
al
18
advocated the use of a dorsal DIP
joint extension splint made of perfo-
rated thermoplastic material. They
assessed 78 patients at a mean of 5
years postinjury and noted a meanex-
tensor lag of 5 and a mean active DIP
joint flexion of 61. The authors re-
ported no skincomplications, contin-
ued splint treatment, and reported no
need for surgery in their study group.
Casting
In 1937, Smillie described casting
of bothIPjoints to manage acute mal-
let finger injuries.
2
The plaster cast
was applied with the PIP joint in 60
of flexion and the DIP joint in slight
hyperextension. Inclusion of the PIP
joint inflexionsubsequently has been
advocated as a means of preventing a
tubular cast from inadvertently fall-
ing off the finger.
19
Although this
technique is infrequently used, cast-
ing may be beneficial in children and
in individuals who are deemed non-
compliant with splint treatment.
Surgical Management
Type I Injury
Although splinting is the treat-
ment of choice for most type I mal-
let finger injuries, surgery may be ad-
vantageous for individuals who are
unable to comply with a splinting
regimen or for patients who would
have difficulty performing their jobs
with an external splint (eg, surgeons,
dentists, musicians).
1,20
To immobi-
lize the DIP joint in extension, a
transarticular Kirschner wire (K-
wire) is driven longitudinally or ob-
liquely across the DIP joint, with the
tip buried in the middle phalanx.
The distal end of the wire is either
capped or cut beneath the skin sur-
face. The K-wire is removed after 6
to 8 weeks, followed by 2 weeks of
nighttime extension splinting.
Open Injuries (Types II and III)
There are few published reports
regarding the management of acute
open mallet injuries. Nakamura and
Nanjyo
20
described three patients
who sustained lacerations over the
DIP joint leading to permanent ex-
tensor lag measuring between 45
and 60. They hypothesized that the
large DIP joint extension deficits
were caused by disruption of both
the terminal extensor tendon and
contiguous oblique retinacular liga-
ments. Allowing the extensor mech-
anism to heal by bridging the scar
with splinting was thought to pre-
dispose the digit to a DIP joint exten-
sor lag and secondary swan neck de-
formity. Open surgical repair was
recommended, using a wire secured
around the DIP joint and a transar-
ticular pin. Doyle
2
suggested a com-
bination of surgical repair and splint-
ing for acute tendon lacerations
overlying the DIP joint. His tech-
nique involves a running suture to
reapproximate both skin and tendon,
followed by application of an exten-
sion splint. The suture is removed
after 10 to 12 days, with splinting
continued for 6 weeks.
Type III mallet deformities,
which involve loss of skin, subcuta-
neous tissues, and tendon substance,
are caused by deep abrasions, crush
injuries, and degloving accidents.
These lesions are often difficult to
treat because of exposure of both
bone and articular cartilage. Staged
reconstructive surgery may be con-
sidered with the goal of providing
early skin coverage, followed by res-
toration of extensor tendon function
with insertion of a free tendon
graft.
2
In severe cases, arthrodesis of
the DIP joint with bone shortening
or fingertip amputation may be
more appropriate.
Mallet Fracture (Type IV)
Management strategies for the
different subtypes of mallet fractures
remain controversial. Treatment al-
ternatives include observation with
reassurance, extension splinting,
closed and open reduction with in-
ternal fixation, and DIP joint arthro-
desis.
2,11,21
A true lateral radiograph
of the injured digit is valuable for de-
termining the size and displacement
of the fracture fragment as well as
Figure 4
Calculations for determining fracture fragment size, fragment displacement, and
distal interphalangeal joint subluxation. A and B = the length of the involved bone
segments at the articular surface of the distal phalanx, C = the amount of fracture
fragment displacement, D = the distance between the midaxial lines of the middle
and distal phalanges. (Adapted with permission from Wehb MA, Schneider LH:
Mallet fractures. J Bone Joint Surg Am 1984;66:658-669.)
Mallet Finger
340 Journal of the American Academy of Orthopaedic Surgeons
the presence or absence of volar sub-
luxation of the distal phalanx (Fig. 4).
Most authorities agree that closed
mallet fracture injuries involving
less than one third of the articular
surface and without DIP joint sub-
luxation can be reliably treated with
extension splinting alone.
Wehb and Schneider
11
and
Schneider
19
advocated nonsurgical
management of nearly all mallet frac-
tures, regardless of the size or dis-
placement of the fracture fragment or
the presence of volar subluxation of
the distal phalanx. They retrospec-
tively reviewed 21 mallet finger frac-
tures managed with either splinting
alone or internal fixation of the frac-
ture fragment using pins and a pull-
out wire.
11
Surgical treatment was
technically demanding, with a higher
complication rate than nonsurgical
management. The only consistent
complication in the nonsurgical
group involved a dorsal prominence
overlying the DIP joint; this same de-
formity was seen in the surgically
treated patients. The authors also
noted remarkable remodeling poten-
tial in the distal phalanx articular
surface (Fig. 5). Additionally, the ra-
diographic appearance of the DIP
joint did not correlate with pain or
finger function at final assessment.
Many surgeons advocate surgical
intervention for mallet fractures in-
volving more than one third of the
articular surface or for fractures with
associated DIP joint subluxation.
Various techniques have been de-
scribed, including transarticular pin-
ning of the DIP joint with or without
fracture fragment fixation, tension-
band constructs,
10,21,22
compression
pinning,
23
and extension block pin-
ning
24,25
(Fig. 6). All of these tech-
niques involve placement of at least
one K-wire to immobilize the DIP
joint in extension. Proponents of
open reduction think that associated
complications can be minimized by
using meticulous surgical tech-
nique. Closed reduction with percu-
taneous pinning has been advocated
by surgeons who are concerned
about complications with open
management. They cite problems re-
lated to reducing the small articular
fragment, the inability to accurately
assess DIP joint congruency, and the
potential for injury to the tenuous
soft-tissue envelope.
24,25
Management of
Chronic Mallet Finger
Injuries
Patients who present for treatment
more than 4 weeks after injury typ-
ically report pain, dissatisfaction
with the appearance of the digit, and
interference with use of the finger for
normal work and recreational activ-
ities. As with acute mallet injuries,
both nonsurgical and surgical treat-
ment measures have been advocated.
Ten patients with chronic (4 to 18
weeks old) mallet finger injuries
without swan neck deformity were
treated with continuous extension
splinting of the DIP joint for 10
weeks.
8
Extensor lag was corrected
to <10 in all but one case. The only
complication was a recurrent mallet
posture in two patients after discon-
tinuation of splint treatment, and
both patients had an excellent result
after reapplying the splint for 8
weeks. Patel et al
8
concluded that
splinting should be considered as an
alternative to surgery for a chronic
mallet finger deformity. Garberman
et al
9
found no differences in out-
come between patients splinted ear-
ly (<2 weeks after injury) and late
(>4 weeks after injury). They recom-
mended DIP joint extension splint-
ing for closed mallet injuries re-
gardless of chronicity, including
fractures involving less than one
Figure 5
Lateral radiograph of a remodeled mallet fracture. The arrows indicate the old frac-
ture line. The distal interphalangeal joint remains congruent.
Figure 6
Extension block pinning technique.
A, With the distal phalanx extended, a
Kirschner wire is inserted proximal to
the fractured fragment. B, The fracture
is reduced manually by directing the
exposed end of the Kirschner wire
distally. C, The wire is drilled into the
head of the middle phalanx, and a
second wire is passed retrograde
across the distal interphalangeal joint.
(Adapted with permission from Tetik C,
Gudemez E: Modification of the
extension block Kirschner wire
technique for mallet fractures. Clin
Orthop 2002;404:284-290.)
Anup A. Bendre, MD, et al
Volume 13, Number 5, September 2005 341
third of the joint surface. Brzezien-
ski and Schneider
1
advocated splint-
ing for all chronic mallet deformities
resulting from either neglect or pre-
vious failed treatment.
Proponents of surgery argue that
chronic mallet finger may develop
pathologic features that interfere
with treatment results.
13
A static
contracture of the extensor mecha-
nism can develop over time, making
it difficult to achieve apposition of
the tendon ends with simple exten-
sion splinting. Surgical procedures
for chronic mallet finger deformities
are intended to stabilize the DIP
joint and improve active DIP joint
extension.
20
Examples include ter-
minal extensor tendon shortening,
tenodermodesis, oblique retinacular
ligament reconstruction, and Fow-
lers central slip tenotomy.
Lind and Hansen
26
described the
abbreviato operation, in which the
extensor tendon is transected near
the DIP joint and repaired directly,
without overlapping and without ex-
cision of damaged tendon tissue.
Scar contraction at the repair site is
thought to correct the flexion defor-
mity. The authors recommended
performing the procedure within 3
months of injury in patients with
marked ligamentous laxity to avoid
progression to a swan neck deformi-
ty. However, the procedure is not
recommended before 6 months to al-
low potential spontaneous correc-
tion of the extensor lag. Their tech-
nique includes using a transarticular
pin to immobilize the DIP joint in
extension for 6 weeks.
Tenodermodesis, originally de-
scribed by Iselin et al,
27
has been
used to manage chronic mallet fin-
ger deformities in both adults and
children.
28
This procedure involves
resection of an elliptical wedge of
skin, tendon, and scar tissue with re-
approximation of the skin and ten-
don as a single unit with sutures
(Fig. 7). Similar to the abbreviato op-
eration, a temporary K-wire is used
to maintain the DIP joint in full ex-
tension during the healing process.
The spiral oblique retinacular lig-
ament reconstruction procedure was
devised to address the imbalance of
flexion and extension forces contrib-
uting to a chronic mallet deformity.
This procedure, which restores the
dynamic tenodesis effect of the ob-
lique retinacular ligaments in coor-
dinating PIP and DIP joint exten-
sion, was originally reported by
Thompson et al
29
and was later mod-
ified by Kleinman and Petersen.
30
A
free tendon graft is harvested and se-
cured distally to the dorsal base of
the distal phalanx. The graft is
passed volarward in a spiral fashion
around the radial aspect of the mid-
dle phalanx and is secured proximal-
ly to the ulnar side of the flexor
tendon sheath at the level of the
proximal phalanx or directly to
bone (Fig. 8). The PIP and DIP joints
are temporarily immobilized with
K-wires before initiating finger mo-
tion exercises.
Fowlers central slip tenotomy cor-
rects for increased extensor tone at
the PIPjoint resulting fromretraction
of the extensor apparatus (Fig. 9).
Houpt et al
31
recommended delaying
the operation until at least 3 months
after injury to allowrestorationof ter-
minal extensor tendon continuity by
scar tissue. To prevent boutonnire
deformity, the triangular ligament
bridging the two conjoined lateral
bands must be preserved when cut-
ting the extensor mechanism.
32
Un-
like the other corrective procedures,
active finger motion is permitted im-
mediately after surgery.
Arthrodesis is the primary sal-
vage procedure for patients with
painful mallet finger injuries second-
ary to arthritis, deformity, infection,
and/or failed prior surgery. Arthro-
Figure 7
Tenodermodesis procedure in which a 3- to 4-mm elliptical wedge of skin, subcuta-
neous tissue, and tendon/scar is resected. A, The full-thickness defect is repaired
with nonabsorbable sutures. B, Before securing the sutures, the distal interpha-
langeal joint is immobilized in extension with a Kirschner wire.
Mallet Finger
342 Journal of the American Academy of Orthopaedic Surgeons
desis of the DIP joint can be effec-
tively performed with K-wires, ten-
sion band wiring, or intramedullary
screw fixation
33
(Fig. 10). The DIP
joint is positioned between neutral
and 10 of flexion. Arthrodesis pro-
vides reliable pain relief and early
PIP joint finger motion.
Complications
Stern and Kastrup
34
reported compli-
cations with nonsurgical and surgi-
cal management in 123 mallet finger
injuries. They noted a 45% compli-
cation rate in the digits treated with
extension splinting and a 53% com-
plication rate in the digits treated
surgically. Most of the complica-
tions from splinting were transient
and resolved with adjustment of the
splint or after completion of treat-
ment. Complications included skin
maceration and ulceration, tape al-
lergy, transverse nail plate grooves,
and splint-related pain. The only
long-term splint complication was a
transverse nail plate groove in one
Figure 9
Dorsal (A) and lateral (B) views of Fowlers central slip tenotomy. The central slip is
transected immediately proximal to its insertion on the base of the middle phalanx.
The lateral bands and triangular ligament are preserved.
Figure 8
Spiral oblique retinacular ligament reconstruction. A, Lateral view. The tendon graft
is secured to the dorsum of the distal phalanx with a pullout suture or wire. The
graft is passed along the radial border of the middle phalanx, deep to the neurovas-
cular bundle and volar to the flexor tendon sheath. B, Volar view. The graft is then
sutured to the ulnar edge of the flexor tendon sheath at the level of the proximal
phalanx. (Adapted with permission from Kleinman WB, Petersen DP: Oblique
retinacular ligament reconstruction for chronic mallet finger deformity. J Hand Surg
[Am] 1984;9:399-404.)
Figure 10
Posteroanterior (A) and lateral (B)
radiographs of a distal interphalangeal
joint arthrodesis. Fixation was achieved
with a headless differential-pitch
compression screw. (Courtesy of
Acutrak Headless Compression Screw
System, Acumed, Hillsboro, OR.)
Anup A. Bendre, MD, et al
Volume 13, Number 5, September 2005 343
patient present after 2 years. In con-
trast to the transient nature of the
splint complications, 76% of the
complications associated with surgi-
cal treatment were long-term. Re-
ported problems included infection,
nail plate deformity, joint incongru-
ity, hardware failure, DIP joint
prominence, and DIP joint deformi-
ty. Five surgically treated patients
eventually underwent a second oper-
ation for pain. There were four DIP
joint arthrodesis procedures and one
fingertip amputation.
Summary
Mallet finger injuries are common
and involve disruption of the termi-
nal extensor mechanism overlying
the DIP joint. Nonsurgical manage-
ment with immobilization of the
DIP joint in extension is the treat-
ment of choice in the vast majority
of cases. Management strategies for
mallet fractures involving more than
one third of the articular surface
and/or fractures with volar sublux-
ation of the distal phalanx remain
controversial. Some authors have re-
ported good functional results with
nonsurgical management; others
have proposed various surgical pro-
cedures to improve fracture and joint
alignment. Although splint treat-
ment is simple and associated com-
plications typically are transient and
benign, patient education, with care-
ful attention to detail, is necessary
to ensure an optimal outcome. Sur-
gical correction of a mallet deformi-
ty may be elected based on the expe-
rience of the treating surgeon with
failure of nonsurgical management.
Patients should be informed of the
potential for a residual DIP extensor
lag and swan neck finger deformity
with all methods of treatment.
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Mallet Finger
344 Journal of the American Academy of Orthopaedic Surgeons