Mallet Finger Treatment
The first-line treatment for mallet finger is continuous splinting of the distal interphalangeal (DIP) joint in extension for 6-8 weeks, with radiographs obtained immediately to identify fractures requiring surgical referral. 1
Initial Diagnostic Evaluation
- Obtain 3-view radiographs of the injured finger immediately to differentiate between tendinous and bony mallet finger, as this distinction determines treatment approach 1
- Standard radiographs are sufficient for diagnosis; advanced imaging (MRI or CT) is not indicated for routine mallet finger evaluation 1
- Apply ice-water mixture for 10-20 minutes with a thin towel barrier to reduce swelling, and avoid attempting to manually straighten the finger before splinting 1
Surgical Indications (Immediate Referral Required)
Refer for surgical intervention if radiographs demonstrate any of the following 2, 1, 3:
- Bony avulsion fractures involving ≥1/3 of the articular surface
- Palmar subluxation of the distal phalanx (volar subluxation on lateral radiographs is an absolute surgical indication, even with small fracture fragments)
- Interfragmentary gap >3mm
- Open injuries
These criteria are critical because involvement of more than one-third of the articular surface typically requires operative fixation to prevent long-term complications 2
Conservative Treatment Protocol (For Non-Surgical Cases)
Splinting Approach
- Immobilize the DIP joint in extension (or slight hyperextension for tendinous injuries) continuously for 6-8 weeks 1, 4, 3
- Stack splints are commonly used and effective 4
- Uninterrupted immobilization is essential—even brief removal of the splint can restart the healing timeline 1
- Some protocols extend full-time splinting to 12 weeks followed by 4 weeks of night splinting, with satisfactory results (56% excellent, 25% good outcomes) 4
Critical Management Considerations
- Begin active finger motion exercises of the PIP and MCP joints immediately while keeping the DIP joint splinted to prevent stiffness 1
- Radiographic follow-up during splinting is necessary to monitor for secondary subluxation, which can develop in approximately 10% of cases even with appropriate splinting 5
- Advise patients to re-evaluate immediately if unremitting pain develops during immobilization 1
Pain Management
- Use topical NSAIDs preferentially over oral NSAIDs for safety reasons 1
- Ice therapy provides effective short-term pain relief during the acute phase 1
- Oral NSAIDs may be used for limited duration if needed 1
Common Pitfalls to Avoid
- Delaying radiographs can lead to missed fractures requiring surgery 1
- Converting a closed injury to an open one through surgical intervention has unacceptable complication rates and should be discouraged 6
- Interrupting splint immobilization restarts the healing process 1
- Failing to monitor for secondary subluxation during conservative treatment, particularly in bony mallet fingers with larger fracture fragments 5
Treatment Outcomes
Conservative splinting achieves restoration of active DIP extension in most cases, with mean extension lag improving from approximately 28 degrees initially to 2.6 degrees at final follow-up 4. However, splinting does not sufficiently prevent secondary subluxation in all cases, making radiographic surveillance essential 5.