What is the best treatment for mallet finger?

Treatment of Mallet Finger

Conservative treatment with continuous splinting for 6-8 weeks is the best treatment for mallet finger, with success rates of approximately 77% and high patient satisfaction. 1

What is Mallet Finger?

Mallet finger is a deformity resulting from the loss of extensor function at the distal interphalangeal (DIP) joint, causing the fingertip to droop. It occurs when the extensor tendon is either:

• Ruptured (soft-tissue mallet)
• Avulsed with a small bone fragment (bony mallet)

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Continuous DIP joint splinting in extension for 6-8 weeks 2, 3

   • For tendon injuries: 8 weeks of splinting
   • For bony injuries: 6 weeks of splinting
   • Followed by 2 weeks of night splinting

2. Splint Options:

   • Dorsal nail-glued splint (preserves digital pulp function, improves compliance) 4
   • Commercial stack splints
   • Custom-molded thermoplastic splints

3. Patient Education:

   • The DIP joint must remain in extension AT ALL TIMES during the treatment period
   • If the finger bends while the splint is off (for cleaning), the 6-8 week clock restarts
   • Splint must be worn continuously, including during sleep and bathing

When Conservative Treatment Fails

If a first attempt at splinting fails, consider:

1. A second trial of conservative management 3
2. Surgical options (only if conservative treatment fails twice or in specific cases)

Surgical Indications (Limited)

Surgery should be reserved for:

• Mallet fractures with palmar subluxation of the distal phalanx 5
• Open injuries that cannot be managed with splinting
• Failed conservative treatment after multiple attempts

Surgical Options

1. Transarticular Kirschner wire fixation 3
2. Conjoint tendon advancement
3. For chronic cases: central slip tenotomy as a salvage procedure

Outcomes and Prognosis

• Conservative treatment success rate: ~77% 1
• Patient satisfaction with conservative treatment: ~83% 1
• Surgical treatment success rate: ~85% for acute cases, ~73% for chronic cases 1

Complications

Conservative Treatment (14.3% complication rate) 4

• Transient ungueal dystrophy (2.5%)
• Swan neck deformity (8.3%, usually resolves)
• Splint detachment (11%, can be reapplied)
• Residual extension deficit (<20° in 14% of cases)

Surgical Treatment

• Higher complication rates than conservative treatment
• Potential for infection, nail deformity, and joint stiffness
• Not recommended for routine soft-tissue mallet injuries due to "unacceptable complication rates" 3

Important Considerations

• Tendon injuries lead to extension deficit in more fingers (20% vs 7.5%) but of lesser degree (16.5° vs 19.1°) compared to bony injuries 4
• The time window for effective conservative treatment continues to be extended, with successful outcomes reported even for chronic cases 3
• Avoid converting closed injuries to open ones through surgical intervention unless absolutely necessary 2
• Rehabilitation exercises are essential after splinting period ends 2

Common Pitfalls to Avoid

1. Inadequate splinting duration - Full 6-8 weeks of continuous splinting is necessary
2. Allowing DIP flexion during splint removal - Even momentary flexion can disrupt healing
3. Unnecessary surgical intervention - Conservative treatment should be the priority for most cases
4. Inadequate patient education - Patients must understand the importance of continuous splinting
5. Failure to recognize palmar subluxation - One of the few true indications for surgery

Conservative management with proper splinting remains the gold standard for treating mallet finger, with surgery reserved for specific cases where conservative treatment has failed or is inappropriate.