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Thanks to a Skiing Injury, Mallet Finger Injuries Get a Review

At first glance, finger fractures can seem like a no big deal kind of problem--until you are the one with the injury. That's what happened to the hand surgeon who wrote this review article. He was out skiing during a break from a medical conference he was attending when he fell and suffered mallet fractures to two fingers. You might think he was really lucky to be with all those other hand specialists because they could fix him right up.

But what really happened was a lively debate about the best way to treat such an injury. You may have seen someone with a mallet fracture without realizing it. The tip of the affected finger is stuck in a bent or flexed position giving the finger a look like a wooden hammer called a mallet. So what was all the fuss about among the group?

Well, mallet injuries can be fairly complex. The surface of the finger joint can be involved. There is avulsion (rupture) of the tendon. The joint may become subluxed (partially dislocated) or fully dislocated. Depending on the location and severity of the injuries, treatment may be accomplished either with a splint to immobilize the joint or surgery to repair the damage.

Okay, so that's sounds easy enough. Why so much argument over that? It turns out that studies have shown surgery involves using a pin to hold the bone fragments together. And there are often many problems associated with the pin such as infection, failure to hold the fractured bone together while it heals, and loss of skin as a result of the infection. But there are times when a pin functions like an internal splint to allow the patient to keep using the hand (such as in the case of a surgeon!).

External splinting is a reasonable conservative (nonoperative) approach, but there are many different kinds of splints to choose from. Some are prefabricated. That means the surgeon can take one off the shelf and slip it on the patient. Those are handy but not always the best choice for patients with special needs. In those cases, the splint may need to be custom made or if already made, custom molded by a hand therapist. There are aluminum splints, rubber coated splints, the Stack splint, the Pryor splint, the Howard splint, and so on. You get the idea that there are many possible choices.

When making a treatment decision, the surgeon must consider many factors such as patient comfort, patient compliance (cooperation), skin problems, and final outcomes. To get to the bottom of what works best, the author of this article reviewed studies done comparing different splints and comparing splints versus surgery for mallet finger injuries. He found some large studies reviewing cases of mallet injuries after treatment was over. There were also a few studies where patients were treated with two different splints and the results compared.

There were a few major findings from these studies:
  • Splinting is best used for most mallet injuries even when there are tendon ruptures, joint damage, and for some cases of partial dislocations.
  • The type of splint isn't nearly as important as just wearing the splint. Patients who wore the assigned splint every day for six weeks had better results no matter which splint was applied.
  • Surgery may be a better option than splinting when the joint is dislocated or a large bone fragment is displaced (no longer lines up with the rest of the bones).

    No matter what kind of treatment is applied, there is always the possibility of complications and post-treatment problems. For example, when it comes to splinting, it can be difficult to find one that will hold up under daily use. Surgery has its own potential problems as mentioned (infection, loss of bone reduction, skin irritations).

    With either surgery or splinting, the finger may still look funny after treatment. Sometimes there is a bump on the back of the finger where a bone callus has built up during the healing process. And there can be an extensor lag, which means the tendon that straightens the joint doesn't pull back far enough to get full finger extension. The joint remains slightly flexed no matter how hard the patient tries to straighten it. A slight extensor lag doesn't affect function.

    Even by pooling all the data published so far, there's plenty of room for some further research in this area. Studies are needed to sort out which splint works best for which patients. Likewise, evidence is needed to support when surgery should be done. For now it looks like splinting is safe and effective and recommended most often. Surgery is saved for complex injuries or splinted injuries that just don't heal. For the best results, patients should be encouraged to do their part and always wear their splints.


    Charles Leinberry, MD. Mallet Finger Injuries. In The Journal of Hand Surgery. November 2009. Vol. 34A. No. 9. Pp. 1715-1717.

    12/17/2009

    *Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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