What is the recommended management for mallet finger?

Management of Mallet Finger

Mallet finger should be treated with continuous splinting of the distal interphalangeal joint (DIPJ) in extension for 6-8 weeks, which is effective for the vast majority of closed injuries regardless of whether they are tendinous or involve small bony avulsions. 1, 2

Initial Assessment and Imaging

• Always obtain radiographs to differentiate between tendinous rupture and bony avulsion, and to assess for DIPJ subluxation 3, 1
• Radiographs detect fracture fragments and determine if the avulsion involves more than one-third of the articular surface 3
• Look specifically for palmar displacement of the distal phalanx or interfragmentary gap >3 mm, which indicates surgical need 3

Non-Operative Management (First-Line Treatment)

Splinting is the gold standard for most mallet finger injuries and should be attempted even in chronic cases 2, 4:

• Immobilize the DIPJ continuously for 6-8 weeks in slight hyperextension for tendon lesions or neutral/straight position for bony avulsions 1, 2
• The splint must maintain uninterrupted immobilization—any interruption restarts the 6-8 week clock 4
• Multiple splint types (dorsal, volar, Stack) show comparable results; choose based on patient comfort and compliance 5
• Even chronic mallet injuries respond well to splinting, and the time window for effective conservative treatment continues to be extended beyond what was previously thought 4

Critical Pitfall

Patient compliance is the primary determinant of success—emphasize that even brief removal of the splint can compromise healing 1, 2

Surgical Indications

Surgery should be reserved for specific scenarios 3, 1, 2:

• Bony avulsion involving ≥1/3 of the articular surface 3, 5
• Palmar subluxation of the distal phalanx that is not reducible with splinting (stage IV injuries) 1
• Interfragmentary gap >3 mm 3
• Open injuries 5
• Failed conservative treatment after 6-8 weeks in patients unable to tolerate repeat splinting 2, 4

Surgical Options

When surgery is indicated, the simplest effective approach should be used 4:

• Transarticular Kirschner wire fixation is the preferred first surgical option for failed splinting or reducible subluxations 1, 4
• Open reduction and internal fixation for large displaced fracture fragments 6, 5
• Salvage procedures (central slip tenotomy) for chronic cases with persistent deformity 4

Surgical Risks

Be aware that surgical intervention carries risks of stiffness, septic arthritis, and osteoarthritis that often exceed the morbidity of prolonged splinting 1

Treatment Algorithm by Injury Type

Closed tendinous rupture (Doyle Type I): 6-8 weeks continuous DIPJ splinting in slight hyperextension 1, 6, 2

Small bony avulsion (<1/3 articular surface, no subluxation): 6-8 weeks continuous DIPJ splinting in neutral position 1, 5

Large bony avulsion (≥1/3 articular surface) with reducible subluxation: Attempt splinting first; if subluxation reduces and maintains, continue 6-8 weeks splinting 1

Large bony avulsion with irreducible subluxation (stage IV): Extra-articular pinning or open reduction with internal fixation 1

Open injuries: Surgical management required 5

Consequences of Non-Treatment

Untreated mallet finger leads to chronic deformity, swan-neck deformity, and DIPJ osteoarthritis 1, 6