What is the initial management for a pediatric patient with a mild mallet deformity confirmed on x-ray?

Initial Management of Pediatric Mild Mallet Deformity

For a pediatric patient with mild mallet deformity confirmed on x-ray, initiate continuous extension splinting of the distal interphalangeal (DIP) joint for 8 weeks, followed by 2 additional weeks of night splinting. 1

Conservative Management Protocol

Splinting is the first-line treatment for pediatric mallet finger deformities and should be attempted before considering any surgical intervention. 1, 2

Splinting Regimen

• Immobilize the DIP joint in full extension (0°) continuously for 8 weeks 1
• Continue night splinting for an additional 2 weeks after the initial 8-week period 1
• Use either custom thermoplastic splints or commercially available finger splints that maintain DIP extension while allowing proximal interphalangeal (PIP) joint motion 1

Expected Outcomes with Conservative Treatment

• Conservative splinting achieves excellent to good results in the majority of cases, even in chronic presentations (4-18 weeks old) 1
• If recurrence occurs after initial splinting (typically within one week), repeat the full 8-week splinting protocol 1
• This approach is predictable, safe, and simple for chronic mallet fingers 1

Critical Considerations for Pediatric Patients

Children present unique challenges due to delays in diagnosis and poor compliance with splinting protocols. 2

Monitoring During Treatment

• Ensure strict adherence to the splinting regimen, as noncompliance is a major cause of treatment failure in children 2
• Educate parents about the importance of maintaining continuous DIP extension during the initial 8-week period 1
• Schedule follow-up visits to assess compliance and skin integrity under the splint 1

When Conservative Treatment Fails

Surgical intervention should only be considered after documented failure of appropriate nonoperative treatment. 2

Indications for Surgical Referral

• Persistent extensor lag greater than 45 degrees after completing the full splinting protocol 2
• Absent active DIP extension despite adequate conservative treatment 2
• Development of swan neck deformity (hyperextension at PIP with flexion at DIP) 3

Surgical Options (if needed)

• Tenodermodesis is the preferred surgical technique for severe chronic soft-tissue mallet fingers in children, achieving restoration of active DIP extension in 100% of cases, though 80% may have residual extensor lag of 20 degrees or less 2
• Surgery should only be performed after 4 weeks of failed splinting attempts 3

Common Pitfalls to Avoid

• Do not accept inadequate splinting duration: The full 8-week continuous immobilization period is essential; shorter periods increase recurrence risk 1
• Do not immobilize the PIP joint: Only the DIP joint should be splinted to prevent stiffness at the PIP joint 1
• Do not rush to surgery: Even chronic cases (up to 18 weeks old) can respond to conservative splinting 1
• Do not discontinue treatment if recurrence occurs: Repeat the full 8-week protocol if deformity recurs after initial treatment 1