Mallet Finger Treatment in Adults with Sports History
For an adult athlete with mallet finger, conservative treatment with continuous splinting of the distal interphalangeal (DIP) joint in extension for 6-8 weeks is the primary treatment, regardless of whether the injury is acute or chronic, tendinous or bony. 1, 2
Initial Management Approach
- Immediate splinting is the gold standard for both acute and chronic mallet finger injuries, with success rates that make it the first-line treatment even when presentation is delayed beyond 10 days 3, 1
- The DIP joint should be immobilized in slight hyperextension for tendinous lesions or in a neutral/straight position for bony avulsions 1
- X-rays are mandatory to differentiate between tendinous rupture and bony avulsion, as this affects splinting position 1
Splinting Protocol
- Uninterrupted immobilization for 6-8 weeks is critical—any interruption restarts the healing timeline 2
- Multiple splint options are equally effective: stack orthosis, thermoplastic orthosis, or aluminum orthosis all produce comparable results in terms of extensor lag and range of motion 4
- Stack orthosis may be preferred as it demonstrates superior grip strength outcomes compared to K-wire fixation and aluminum orthosis at 12 weeks 4
- After the initial 6-8 weeks, gradual weaning with an overnight splint for an additional 4-6 weeks is recommended 3
When Surgery is Indicated
Surgery should be reserved for specific failures or anatomical situations, not as first-line treatment:
- Stage IV mallet finger (irreducible DIP joint subluxation with bony fragment) requires surgical intervention with extra-articular pinning 1
- Failed conservative treatment after a complete 6-8 week trial may warrant transarticular K-wire fixation 2
- Open injuries should still be treated with splinting when possible, as converting closed injuries to open surgical cases increases complication rates unacceptably 2
Critical Pitfalls to Avoid
- Never convert a closed injury to an open one surgically without clear indication—complication rates (stiffness, septic arthritis, osteoarthritis) are unacceptably high 1, 2
- Patient compliance is the primary determinant of success—emphasize that any interruption in splinting during the initial 6-8 weeks requires restarting the entire immobilization period 2
- Chronic injuries (>10 days old) still respond well to conservative treatment—delayed presentation is not an indication for surgery 3, 1
Return to Sports Considerations
- The minimum immobilization period is 6-8 weeks before any consideration of return to activity 3, 1
- Gradual return with protective splinting for an additional 4-6 weeks during the weaning phase protects against re-injury 3
- If left untreated, mallet finger progresses to swan-neck deformity and DIP joint osteoarthritis, which will permanently affect athletic performance 1
Surgical Technique (When Required)
If surgery becomes necessary after failed conservative treatment:
- Transarticular K-wire fixation is the preferred surgical option, maintaining the DIP joint at 0° extension for 6 weeks 3, 2
- Alternative techniques include deepithelialized pedicled skin flap for chronic cases, showing excellent or good results in 121/121 cases 3
- Elastic fixation with two K-wires may provide better stability than conventional single-wire techniques for bony avulsions 5