What is the postoperative protocol after mallet finger surgery?

Postoperative Protocol After Mallet Finger Surgery

After mallet finger surgery, immobilize the DIP joint in extension with a Kirschner wire and thermoplastic splint for 6 weeks, then begin aggressive active finger motion exercises immediately to prevent stiffness, which is the most functionally disabling complication. 1, 2

Immediate Postoperative Period (0-6 Weeks)

Immobilization Protocol

• Maintain rigid immobilization for 6 weeks using a thermoplastic splint with the DIP joint held at 0° extension, supported by a Kirschner wire placed intraoperatively 2
• The wire and splint combination provides stability while the surgical repair heals 2
• Full-time splint wear is critical during this phase—any flexion of the DIP joint can disrupt the repair 2

Early Monitoring

• Evaluate for postoperative complications within 2 weeks by the operating surgeon, looking specifically for signs of infection, skin necrosis, wire migration, or loss of fracture reduction 3, 1
• Monitor for unremitting pain, which may indicate inadequate fixation, pulley system injury, tendon adhesions, or re-rupture 1

Transition Phase (6-10 Weeks)

Splint Weaning

• At 6 weeks, remove the Kirschner wire and begin gradual weaning from full-time immobilization 2
• Continue overnight splinting for an additional 4-6 weeks (total of 10-12 weeks from surgery) to protect the repair during sleep when involuntary flexion may occur 2, 4
• Some protocols extend full-time splinting to 12 weeks for tendinous injuries, though this is primarily for non-operative cases 4

Initiation of Motion

• Begin aggressive active finger motion exercises immediately after the 6-week immobilization period ends 1, 2
• Early motion is essential—the primary goal is preventing stiffness, which causes more functional disability than a small residual extensor lag 1, 5
• Patients should move the finger through complete range of motion multiple times daily 1

Rehabilitation Phase (10+ Weeks)

Exercise Progression

• Implement home-based exercise programs focusing on active DIP joint flexion and extension 1
• Target achieving 65-75° of active DIP joint flexion, which represents approximately 65-70% of the unaffected side 5, 6
• Expect a small residual extension deficit of 0-6° at final follow-up, which is functionally acceptable 2, 5, 6

Common Pitfalls to Avoid

• Do not delay motion exercises beyond 6 weeks—prolonged immobilization leads to joint stiffness and impaired flexion that may never fully recover 5
• Avoid passive stretching or overly aggressive therapy initially—this can disrupt the repair or cause pain that limits patient participation 1
• Do not discontinue night splinting abruptly—gradual weaning over 4-6 weeks prevents loss of extension during the vulnerable healing phase 2

Expected Outcomes

Functional Results

• Mean extension deficit of 6° or less at 1 year 2, 5
• Active DIP joint range of motion reaching 58-68° (65-70% of unaffected side) 5, 6
• Excellent or good results in 80-90% of patients by Crawford criteria 2, 6
• Pain-free function in the vast majority of cases 6, 7

Follow-Up Timeline

• 2 weeks: Surgical complication check 3
• 6 weeks: Wire removal and motion initiation 2
• 10-12 weeks: Discontinue night splinting 2
• 3-6 months: Assess final functional outcome 2, 6

The critical distinction between surgical and non-surgical protocols is that surgery allows for earlier definitive motion at 6 weeks rather than 8-12 weeks, but the fundamental principle remains the same: adequate immobilization followed by immediate aggressive mobilization to prevent stiffness. 1, 2, 5