What is the recommended treatment for a patient with mallet finger, including any necessary immobilization, pain management, and potential referrals to a specialist?

Mallet Finger Treatment

Splint the distal interphalangeal (DIP) joint in full extension or slight hyperextension continuously for 8 weeks, followed by 2 additional weeks of night splinting, without any interruption—even brief removal restarts the healing timeline. 1, 2, 3

Immediate Assessment and Imaging

• Obtain 3-view radiographs immediately (anteroposterior, lateral, oblique) to differentiate between tendinous mallet finger and bony mallet finger with avulsion fracture. 1, 2
• Delaying radiographs risks missing fractures that require surgical intervention. 1
• Do not use MRI or CT for routine mallet finger—standard radiographs are sufficient. 1

Initial Pain and Swelling Management

• Apply ice-water mixture for 10-20 minutes with a thin towel barrier to reduce swelling. 1
• Do not apply heat. 1
• Do not attempt to straighten the finger manually before splinting. 1
• Splint the finger in the position found until proper evaluation and definitive splinting can be performed. 1

Conservative Treatment Protocol (Non-Surgical Cases)

Indications for conservative management:

• Tendinous mallet finger (no fracture) 2, 3
• Bony mallet finger with avulsion fracture involving less than 1/3 of the articular surface 1, 3, 4
• No palmar subluxation of the distal phalanx 1, 3
• Interfragmentary gap ≤3mm 1

Splinting protocol:

• Immobilize the DIP joint in full extension or slight hyperextension for 8 continuous weeks. 1, 2, 3, 5
• Follow with 2 additional weeks of night splinting only. 6
• Critical: Even brief removal of the splint restarts the entire 8-week healing timeline—patient compliance is essential. 1, 3
• The proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints should remain free to move. 1

This protocol works even for chronic mallet fingers (4-18 weeks old), with excellent to good results in 90% of cases. 6

Rehabilitation During Splinting

• Begin active finger motion exercises of the PIP and MCP joints immediately while keeping the DIP joint splinted to prevent stiffness. 1
• The DIP joint must remain continuously immobilized throughout the 8-week period. 1, 3

Surgical Indications (Immediate Referral Required)

Refer to hand surgery or orthopedics if any of the following are present:

• Open mallet finger injuries 3, 4
• Avulsion fracture involving ≥1/3 of the articular surface 1, 3, 4
• Palmar (volar) subluxation of the distal phalanx—this is an absolute surgical indication even with small fracture fragments 1, 3, 4
• Interfragmentary gap >3mm 1
• Irreducible subluxation 1
• Failed conservative management after 8 weeks of proper splinting 3, 4
• Absence of full passive extension of the DIP joint 3

Follow-Up and Red Flags

• Unremitting pain during immobilization warrants immediate re-evaluation—may indicate inadequate fixation, pulley injury, tendon adhesions, or re-rupture. 7, 1
• If the deformity recurs within a week after completing treatment, restart the full 8-week splinting protocol—this typically results in full recovery. 6
• A second trial of conservative management can be offered if the first 8-week course fails, though some patients may prefer surgical intervention at that point. 5

Pain Management

• Topical NSAIDs are preferred over oral NSAIDs for safety reasons, though oral NSAIDs can be used for limited duration if needed. 8
• Ice therapy provides effective short-term pain relief during the acute phase. 8, 1

Common Pitfalls

• Converting a closed injury to an open one through surgical intervention has unacceptable complication rates—prioritize conservative management whenever appropriate. 5
• Patient non-compliance with continuous splinting is the most common cause of treatment failure—emphasize that even removing the splint briefly to wash the finger restarts the 8-week clock. 1, 3
• Missing volar subluxation on lateral radiographs—this finding mandates surgical referral regardless of fracture size. 1