What is the recommended care for a patient with mallet finger?

Mallet Finger Care

Mallet finger should be treated with continuous splinting of the distal interphalangeal (DIP) joint in extension (or slight hyperextension for tendon injuries) for 6-8 weeks, which is the gold standard for most cases and yields excellent results while minimizing complications. 1, 2, 3

Initial Assessment and Diagnosis

• Obtain radiographs immediately to differentiate between tendon rupture and bony avulsion, and to assess fracture size and joint subluxation 1, 4
• Mallet finger presents with loss of active DIP joint extension following axial load or forced flexion injury to the fingertip 1, 3
• Use Tubiana's classification to guide treatment: assess articular fragment size and presence/reducibility of DIP joint subluxation 1

Conservative Management (First-Line Treatment)

Splinting is the treatment of choice for the vast majority of mallet finger injuries, including both acute and chronic cases. 2, 3, 5

Splinting Protocol:

• Duration: 6-8 weeks of uninterrupted immobilization 2, 3
• Position: DIP joint in slight hyperextension for pure tendon injuries, or neutral/straight position for bony avulsions 1
• Splint type: Dorsal glued splint is effective; multiple splint types show comparable results 1, 4
• Critical requirement: Patient compliance is essential—the splint must remain in place continuously without interruption 2, 3

Key Points:

• Splinting is highly effective, safe, and reproducible for both acute and chronic lesions 2
• Even delayed presentation (weeks to months after injury) can be successfully treated with splinting 2
• If initial splinting fails, consider a second trial of conservative management before proceeding to surgery 2

Surgical Indications (Limited Scenarios Only)

Surgery should be reserved for specific situations:

1. Open injuries (though conversion of closed to open injury should be avoided due to high complication rates) 2, 4
2. Large bony avulsion: Fracture involving ≥1/3 of the articular surface 4, 3, 5
3. Irreducible volar subluxation of the distal phalanx (Stage IV) 1, 4
4. Failed conservative treatment after appropriate splinting trial 2, 3
5. Patients unable to work with splint in position 3

Surgical Approach:

• First choice: Transarticular Kirschner wire fixation across the DIP joint for 6-8 weeks 2
• Alternative: Extra-articular pinning for Stage IV mallet finger 1
• Complications of surgery include stiffness, septic arthritis, osteoarthritis, nerve dysfunction, and wound healing issues—far more serious than splinting complications 1, 5

Critical Pitfalls to Avoid

• Never interrupt splinting during the 6-8 week period, as this resets the healing timeline 2, 3
• Avoid unnecessary surgery: Nearly all mallet fingers can be treated conservatively with comparable or superior outcomes to surgery 5
• Do not convert closed injuries to open through surgical intervention unless absolutely indicated 2
• Recognize that untreated mallet finger leads to chronic deformity, swan-neck deformity, and DIP joint osteoarthritis 1

Adjunctive Care

• Patient education on ergonomic principles and activity modification during healing 6
• Pain management: Topical NSAIDs preferred over systemic agents for safety 6
• Consider occupational therapy referral for splint fabrication and patient education on proper use 7

Evidence Quality Note

The recommendation for conservative splinting is supported by multiple high-quality studies showing excellent outcomes with minimal morbidity 2, 3, 5. The surgical literature consistently demonstrates higher complication rates without significant functional benefit for most cases 5.