When to Refer Mallet Finger to Orthopedics
Refer mallet finger injuries to orthopedics when there is a fracture involving >30% of the articular surface, volar subluxation of the distal phalanx, open injury, or failure of conservative splinting treatment. 1, 2, 3
Immediate Orthopedic Referral Indications
The following conditions warrant early orthopedic consultation:
- Large avulsion fractures: Fractures involving ≥30-33% of the articular surface of the distal phalanx require surgical evaluation 1, 2, 3
- Volar subluxation: Any palmar displacement of the distal phalanx indicates joint instability and necessitates referral 1, 2, 3
- Open injuries: All open mallet finger injuries should be referred for surgical management 2
- Inability to achieve full passive extension: If the DIP joint cannot be passively extended to neutral, surgical intervention may be needed 1
- Avulsed bone fragments that fail closed reduction: When fracture fragments cannot be adequately reduced with splinting alone 1
Initial Assessment Before Referral Decision
Obtain standard 3-view radiographs (PA, lateral, and oblique) to identify the presence and size of any bony avulsion 4, 5. The American College of Radiology recommends these views as sufficient for osseous mallet injuries 4.
Key radiographic findings to evaluate:
- Percentage of articular surface involved in fracture 4, 1
- Presence of volar subluxation of the distal phalanx 1, 2
- Size and displacement of avulsed fragments 4, 1
Conservative Management (No Referral Needed)
Most mallet finger injuries can be managed in primary care without orthopedic referral 5, 1, 2. Uncomplicated injuries—defined as tendinous ruptures or small avulsion fractures (<30% articular surface) without subluxation—should be treated with:
- Strict continuous splinting of the DIP joint in full extension or slight hyperextension for 8 weeks 5, 1, 2
- The splint must not be removed during this period, as even brief flexion can restart the healing timeline 1
- After 8 weeks, gradual weaning with nighttime splinting for an additional 4-6 weeks 5, 1
When to Refer After Failed Conservative Treatment
Refer if there is persistent extension lag or deformity after completing the full 8-week splinting protocol 1, 2. Patient compliance is essential for success, and failure of conservative management is an accepted indication for surgical intervention 1, 2.
Important Caveats
While the literature suggests surgery for fractures >30-33% of the articular surface, there is ongoing controversy about absolute surgical indications 3. Some studies show comparable outcomes between surgical and nonsurgical management even in complex cases 3. However, the presence of volar subluxation combined with large fracture fragments represents the strongest indication for orthopedic referral 1, 2, 3.
Early referral is recommended if there is any clinical concern or uncertainty about the injury severity 1. MRI without IV contrast can be obtained if clinical examination is equivocal, though it is not routinely necessary when the diagnosis is clear 4.