What is the initial management for a pediatric patient with a mild mallet deformity and an intact extensor mechanism?

Management of Pediatric Mild Mallet Deformity with Intact Extensor Mechanism

For a pediatric patient with mild mallet deformity visible on x-ray but with an intact extensor mechanism on physical exam, initiate conservative treatment with continuous extension splinting for 4-6 weeks, as this approach achieves excellent outcomes in 99% of pediatric mallet finger cases treated nonsurgically. 1

Initial Conservative Management

• Begin extension orthosis/splinting immediately for continuous wear over 4-6 weeks, as this is the standard first-line treatment for pediatric mallet finger injuries 1
• The splint must maintain the distal interphalangeal (DIP) joint in full extension or slight hyperextension while allowing proximal interphalangeal (PIP) joint motion 1
• Radiographs are sufficient for initial evaluation of osseous mallet injuries to assess for bony avulsion fragments 2

Key Radiographic Assessment Points

• Evaluate whether any bony fragment involves more than one-third of the articular surface, as this typically requires operative fixation 2
• Check for palmar displacement of the distal phalanx or interfragmentary gap >3 mm, both of which are surgical indications 2
• Since your case shows mild deformity with intact extensor mechanism on exam, these concerning radiographic features are likely absent, supporting conservative management 2

Treatment Adherence Considerations

• Emphasize strict compliance with continuous splinting, as adherence is the strongest predictor of successful outcomes 1
• Nonadherent patients experience residual extensor lag in 67% of cases versus only 11% in compliant patients 1
• Complications occur in 50% of nonadherent patients compared to only 8% in those who maintain proper splinting 1

Expected Outcomes with Conservative Treatment

• Mean extension lag after nonsurgical treatment is approximately 1 degree in compliant pediatric patients 1
• Patients presenting acutely (within 28 days) achieve better outcomes with only 12% residual extension lag and 9% complication rate 1
• The majority of pediatric mallet finger injuries achieve good outcomes with extension orthoses alone 1

When Surgery Becomes Necessary

• Reserve surgical intervention for failure of 4 weeks of proper splinting or severe chronic cases with extensor lag >45 degrees and absent active DIP extension 3, 4
• Absolute indications for acute surgery in pediatric mallet finger remain unclear, making conservative management the appropriate initial approach 1
• Surgical options like tenodermodesis are reserved for severe chronic soft-tissue mallet deformities that have failed conservative treatment 3

Common Pitfalls to Avoid

• Do not accept partial compliance with splinting—the DIP joint must remain continuously immobilized in extension for the full treatment duration 1
• Avoid premature discontinuation of splinting before 4-6 weeks, as incomplete healing leads to recurrent deformity 1
• Do not overlook the need for close follow-up to monitor adherence, as this is the primary determinant of success 1