Treatment of Pediatric Mallet Finger
Conservative management with continuous extension splinting of the distal interphalangeal (DIP) joint for 6-12 weeks is the primary treatment for pediatric mallet finger, achieving excellent outcomes in the vast majority of cases without surgery. 1, 2
Initial Assessment and Classification
When evaluating pediatric mallet finger, obtain radiographs to distinguish between:
- Soft tissue (tendinous) mallet: Pure extensor tendon disruption
- Bony mallet: Avulsion fracture at the extensor tendon insertion 1
For bony mallets specifically, assess whether:
- The fracture involves >1/3 of the articular surface
- There is palmar displacement of the distal phalanx
- An interfragmentary gap >3 mm exists 1
These findings indicate potential need for operative fixation, though most pediatric cases still respond to conservative treatment 1, 2.
Primary Treatment: Extension Splinting
Immobilize the DIP joint in full extension (not hyperextension) for continuous wear. The evidence supports:
- Duration: 6-12 weeks of full-time immobilization 3, 4
- Splint options: Stack splint, Quickcast, or custom thermoplastic orthosis 5, 2
- Quickcast demonstrates superior outcomes with significantly fewer skin complications (33% vs 64%) and less pain (11.2 vs 21.6) compared to custom thermoplastic splints 5
After the initial immobilization period, consider an additional 4 weeks of night-time splinting to prevent recurrence 4.
Critical Success Factors
Treatment adherence is the single most important predictor of outcome. Non-adherent patients experience:
- Residual extensor lag in 67% vs 11% in compliant patients
- Complications in 50% vs 8% in compliant patients 2
Uninterrupted immobilization is essential - even brief periods without the splint can compromise healing 3. Educate families that the 6-8 week period must be continuous, and any interruption may require restarting the treatment timeline.
Timing Considerations
Delayed presentation (>28 days) worsens outcomes but does not preclude conservative treatment:
- Acute presentation: 12% residual lag, 9% complications
- Delayed presentation: 25% residual lag, 19% complications 2
Even chronic mallet fingers presenting months after injury can respond to splinting, though the acceptable time window continues to be extended in the literature 3.
Expected Outcomes with Conservative Treatment
With proper splinting and adherence, expect:
- Mean final extension lag of 1-2.6 degrees 2, 4
- Mean DIP flexion of 68 degrees at final follow-up 4
- 56% excellent and 25% good results by Crawford criteria 4
- 99% of pediatric cases successfully managed non-operatively 2
Surgical Indications
Surgery is rarely indicated in pediatric mallet finger. Consider operative intervention only when:
Bony mallets with:
1/3 articular surface involvement
- Palmar displacement of distal phalanx
- Interfragmentary gap >3 mm 1
Failed conservative treatment after:
If surgery is required, options include:
- Transarticular Kirschner wire fixation (preferred first-line surgical option) 3
- Tenodermodesis for severe chronic cases (achieves active extension restoration in 100%, though 80% have residual lag ≤20 degrees) 6
Common Pitfalls to Avoid
- Never convert a closed injury to open surgically - unacceptable complication rates make this approach inadvisable 3
- Do not accept "partial compliance" - emphasize that any break in immobilization compromises outcomes 2
- Avoid hyperextension of the DIP joint during splinting, which can cause skin breakdown 5
- Monitor for skin complications during treatment, particularly with thermoplastic splints 5
Referral Considerations
Per pediatric surgical guidelines, hand trauma in children including tendon injuries should be referred to a pediatric plastic surgeon or pediatric surgical specialist with appropriate training 1. However, most pediatric mallet fingers can be successfully managed by the primary treating physician with appropriate splinting protocols 2.