What is the primary treatment for mallet finger without fracture?

Primary Treatment of Mallet Finger Without Fracture

For tendinous mallet finger without fracture, splint the distal interphalangeal joint (DIPJ) in extension continuously for 6-12 weeks, followed by nighttime splinting for an additional 2-4 weeks. 1, 2

Splinting Protocol

Splint Type and Position

• Apply a dorsal splint (Stack splint or aluminum splint) that immobilizes the DIPJ in slight hyperextension or neutral extension 1, 3
• The splint should be padded and comfortably tight but not constrictive 4
• Keep the proximal interphalangeal (PIP) joint free to move to prevent unnecessary stiffness 4

Duration of Immobilization

• Continuous full-time splinting for 6-8 weeks is the standard approach, though some protocols extend this to 12 weeks for optimal outcomes 1, 2
• After full-time immobilization, continue nighttime splinting for an additional 2-4 weeks 5, 2
• The longer 12-week protocol (full-time) followed by 4 weeks of night splinting has shown 81% excellent-to-good results with mean extension lag of only 2.6 degrees 2

Critical Management Points

Patient Compliance

• Strict adherence to continuous splinting is essential - even brief removal of the splint can restart the healing timeline 1, 3
• Educate patients that the DIPJ must remain in extension 24 hours per day during the initial treatment period 1
• If the splint is removed and the finger droops, the 6-8 week clock resets 1

Active Motion Protocol

• Begin active motion exercises immediately for all unaffected joints (PIP joint and metacarpophalangeal joint) to prevent hand stiffness 4, 6
• Active finger motion of unaffected joints does not adversely affect adequately stabilized fractures 4, 6
• Stiffness is one of the most functionally disabling complications and can be very difficult to treat after healing 4, 6

Expected Outcomes

• Conservative splinting achieves excellent-to-good results in 81% of cases when compliance is maintained 2
• Mean final extension lag is typically 2-6 degrees with proper treatment 2
• Even chronic mallet fingers (4-18 weeks old) respond well to conservative splinting, with 90% achieving excellent-to-good results after 8 weeks of continuous immobilization 5

Common Pitfalls

• Premature discontinuation of splinting is the most common cause of treatment failure 1, 3
• If recurrence occurs after splint removal, reinstitute full-time splinting for another 8 weeks - this typically results in full recovery 5
• Over-immobilization of unaffected joints (PIP and MCP) leads to unnecessary stiffness 4
• Failure to educate patients about the consequences of non-compliance 1

When Surgery Is NOT Indicated

• Pure tendinous mallet finger without fracture is managed conservatively 1, 3
• Surgery is reserved for bony mallet fingers with large fracture fragments (>1/3 articular surface) and volar subluxation that cannot be reduced with splinting 1