What is the recommended treatment for mallet finger?

Mallet Finger Treatment

Conservative treatment with continuous splinting of the distal interphalangeal joint (DIP) in extension for 6-8 weeks is the recommended first-line treatment for most mallet finger injuries. 1

Initial Assessment and Classification

• Determine if the mallet finger is:

  • Tendinous (extensor tendon rupture at insertion)
  • Bony (avulsion fracture at insertion site)
  • Open or closed injury
  • Presence of palmar subluxation of distal phalanx

• Obtain radiographs to assess:

  • Presence of avulsion fracture
  • Size of fracture fragment (if present)
  • Articular surface involvement
  • Subluxation of distal phalanx 2

Treatment Algorithm

Conservative Management (First-line)

1. Splinting Technique:

   • Immobilize the DIP joint in full extension or slight hyperextension
   • Keep the proximal interphalangeal (PIP) joint free
   • Apply splint on dorsal surface for tendinous injuries
   • Consider volar splint for skin problems on dorsum 3, 1

2. Duration of Splinting:

   • Continuous splinting for 6-8 weeks (24 hours/day)
   • Additional 2-4 weeks of night splinting
   • Longer immobilization (up to 12 weeks continuous) may improve outcomes for tendinous injuries 4

3. Splint Options:

   • Stack splint (most common)
   • Custom-made thermoplastic splints
   • Padded aluminum-alloy malleable finger splints
   • Ensure splint is robust enough for everyday use 5

4. Patient Education:

   • Emphasize importance of strict compliance with splinting
   • Instruct on skin care and hygiene under splint
   • Perform active finger motion exercises for non-splinted joints 2

Surgical Management (Selected Cases)

Surgical intervention is indicated for:

• Open injuries
• Avulsion fractures involving ≥1/3 of articular surface
• Palmar subluxation of distal phalanx
• Failed conservative treatment after 8 weeks 3, 1

Surgical options include:

• Kirschner wire fixation
• Extension block pinning
• Tension band wiring
• Hook plate fixation

Management of Chronic Mallet Finger

• For chronic mallet fingers (4-18 weeks old), conservative splinting can still be effective
• Immobilize DIP joint in extension for 8 continuous weeks followed by 2 weeks of night splinting 6
• If deformity recurs after treatment, repeat splinting for additional 8 weeks 6

Follow-up and Monitoring

• Regular follow-up at 1-2 week intervals initially to ensure proper splint fit
• Monitor for skin complications under splint
• Assess for treatment failure (persistent extension lag >10°)
• Evaluate for complications:
  • Skin maceration
  • Pressure sores
  • Joint stiffness
  • Recurrent deformity

Rehabilitation

• After splinting period, begin gentle active range of motion exercises
• Avoid passive stretching of the DIP joint for 2-4 weeks after splint removal
• Consider night splinting during rehabilitation phase if extension lag recurs

Pitfalls and Caveats

• Removing the splint prematurely can lead to treatment failure
• Patient non-compliance is a major cause of treatment failure
• Splints must be kept dry and clean to prevent skin complications
• Avoid forceful flexion of the DIP joint during early rehabilitation
• Be aware that some extension lag (5-10°) may persist even after successful treatment

The evidence strongly supports conservative management with splinting as the first-line treatment for most mallet finger injuries, with surgical intervention reserved for specific indications. Proper patient education and compliance with splinting protocols are crucial for successful outcomes.