Mallet Fingers

Mallet Fingers: why do we spend so much time treating this injury?

Without proper treatment the injury can not heal properly
The fingertip or distal interphalangeal joint (DIPJ) will not be able to straighten
An untreated mallet injury can cause long term changes to the finger – Swan Neck Deformity (SND)
SND can be very irritating and annoying for the patient

What is a Mallet finger?

Avulsion of the terminal extensor tendon at the dorsal lip of the distal phalanx
Can be bony or tendinous in nature.
All mallet injuries require an x-ray to determine if they are bony or tendinous.
The knowledge of bony v tendinous can determine the length of treatment. Bony mallets heal faster.
Large bony fragments can cause the DIPJ to sublux & require a surgical consultation.

What do hand therapists do for a mallet finger?

Educate the patient on treatment options
Refer the patient for an x-ray if they have not had one
Measure the initial lag – if patient presents without already being in a splint.
Fabricate a custom made splint for optimal position and comfort – very important as the splint must be worn 24/7.
Monitor skin condition at regular appointments
Assist patients to continue normal activities during splinting (e.g. waterproofing for swimming/ surfing)
Ensure unaffected joints continue moving well
Guide patient through splint weaning after full-time splinting ceases
Return patient to maximum range of motion, function and strength

Why refer to a hand therapist and not use a pre-fabricated splint?

Pre-fabricated splints do not allow for customised positioning
They can include the proximal interphalangeal (PIPJ), which needs to be unrestricted and regularly moving
Customised splints are comfortable
Hand therapists monitor the patients skin condition during splinting
Hand therapists can teach patients how to safely change their splint without allowing any DIPJ flexion

Swan Neck Deformity (SND)

SND occurs when the terminal extensor tendon remains unattached, such as in an untreated mallet finger injury.
The extensor tendon then overpulls the middle finger joint (PIPJ) into hyperextension while the DIPJ remains in a flexed position
B. SND can also occur from other conditions such as Rheumatoid Arthritis, and the treatment for these can differ.

What do Hand Therapist’s do for a SND post mallet injury?

Prevention: by treating mallet finger as an acute injury.
For long standing untreated mallet injuries a splint is made to prevent hyperextension of the PIPJ
A sterling silver ring can be measured and ordered to provide a long-term and durable option

Case study

Patient attended hand therapy after seeing their regular physiotherapist for a mallet finger.
The patient had had a pre-fabricated splint taped-on for six weeks.
The tip flexed immediately on removal of the splint.

Our treatment

Education on our treatment process, importance of splint wearing.
X-ray: determine if tendinous or bony. X-ray showed no bony involvement, therefore tendinous in nature and splinting time increased.
Thermoplastic splint fabricated and taped on: Splinted 24/7 for eight weeks.
Regular reviews to check skin and splint selection.
Encouragement to keep moving PIPJ.
Active extension checked at eight weeks.
Splint weaning process for four weeks to gradually allow flexion and maintain extension after full time splinting completed.