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The long term results of mallet finger injury a retrospective study of one hundred cases
The Long Term Results o f Mallet Finger Injury A Retrospective Study o f One Hundred Cases J. G. Moss, and R. F. Steingold
THE LONG TERM RESULTS OF M A L L E T FINGER INJURY A RETROSPECTIVE S T U D Y OF ONE H U N D R E D CASES
J. G. MOSS and R. F. STEINGOLD, Leicester SUMMARY
One hundred patients with mallet finger injuries were reviewed and examined three to five years after injury. Twenty nine patients still had symptoms consisting mainly of pain and cold intolerance. The degree of residual deformity, presence of a fracture, or delay in treatment were not related to symptoms. This common injury was first described in the literature by Segond in 1880, although the term 'mallet finger', was not coined until some years later. Previous authors have used the degree of residual deformity as a parameter for assessing the results of treatment, (Smillie, 1937; Pratt, 1957; Stack, 1962; Abouna, 1968). Very few authors have considered in any detail the long term symptoms of mallet finger, (Hallberg, 1960; Smillie, 1937). The aim of this study was to investigate the incidence of such symptoms and to assess any correlation with the digit injured, presence of a fracture, delay in treatment or residual deformity. MATERIAL AND METHODS
One hundred and seventy eight patients from the period 1977 to 1979 with a mallet finger injury were requested to attend for review. Eighty-two patients reported initially, and a further eighteen reported after a second or third letter. The remaining seventy-eight patients consisted of those who had moved from the area or were simply untraceable. The one hundred patients who returned for review were questioned and examined by one of us, (J.G.M.). The minimum length of time since injury was three years. Ninety of the patients had been treated in the same manner, using a plastic mallet splint (Stack, 1969), for six to eight weeks. The remaining ten were treated with a variety of splints and plasters. Particular attention was paid to any symptoms experienced by the patients and these were categorised into three groups: moderate symptoms, minimal symptoms and cold intolerance. Moderate symptoms denoted pain sufficiently severe to interfere with the patient's job. Minimal symptoms included slight pain, occasional reluctance to use the finger, poor grip and the finger catching on objects. Cold intolerance was a frequent symptom and therefore allocated a separate category. The degree of residual deformity was measured using a finger goniometer and compared with the normal hand. At the distal interphalangeal joint, extensor lag, fixed flexion deformity and loss o f active flexion were measured, and at the proximal interphalangeal joint, loss of active flexion and swan neck deformity. The group of symptomatic patients was then compared with the asymptomatic group with regard to the digit injured, presence of a fracture, delay in treatment and residual deformity. J. G. Moss, Western General Hospital, Crew Road, Edinburgh EH4 2XU The Hand-- Volume 15
No. 2
1983
151
The Long Term Results of Mallet Finger 1njury A Retrospective Study- of One Hundred Cases J. G. Moss, and R. F. Steingold
RESULTS Fifty-one patients were male and forty-nine female, the age range being ten years to seventy-six. The mean female age was fifty years and the mean male age, thirty-nine years. Twenty-nine of the hundred patients reviewed had symptoms; these were categorised as in Table I.
TABLE I
SYMPTOMATIC PATIENTS Symptoms
Number of patients
Pain in cold weather Minimal symptoms Moderate symptoms
13 16 2
Two patients had both cold intolerance and mild pain. Both the patients with moderate symptoms had pain in the digit which was severe enough to interfere with their job (porter and teacher). In the minimal symptom group, fourteen o f the sixteen patients experienced mild pain at the distal phalanx; six occasionally avoided using the finger because o f this. Three of the patients complained o f poor grip and two noticed the finger occasionally catching on objects. We were surprised that only two patients noticed the digit catching on objects and that one of these had an extension lag of only five degrees. Cold intolerance consisted of discomfort or pain in the distal phalanx when exposed to a cold environment and accounted for about half o f the symptomatic group. It is well recognised (Allen, 1980), but its aetiology is not clear; (Jones, 1980) suggested a loss of local axon reflex in digital replantation patients. Those patients with cold intolerance found it an annoying symptom, much more so than the patients with mild digital pain, poor grip or the finger catching on objects. Tables II, III and IV show the digit injured, the delay before the patient presented for treatment and the x-ray result; (X-rays were only available for seventyeight patients). TABLE 11 DIGIT I N J U R E D
Digit
Thumb Index Middle Ring Little
Asymptomatic Group
Symptomatic Group
1 8 22 22 18
3 6 5 5 10
It is interesting that approximately one quarter o f the fingers were symptomatic whereas three of the four thumb injuries had symptoms. 152
The Hand-- Volume 15
No. 2
1983
The Long Term Results of Mallet Finger Injury A Retrospective Study of One Hundred Cases J. G. Moss, and R. F. Steingold TABLE III D E L A Y IN TREATMENT
Delay
Asymptomatic G r o u p s
> 1 week <
Symptomatic Group
50 22
22 6
Statistically there is no difference between the two groups in this table. However there are relatively more asymptomatic patients in the group whose treatment was delayed for more than one week. This may perhaps reflect the type of patient, in that those who delay seeking treatment are less likely to complain of residual symptoms. TABLE IV X-RAY RESULT
X-ray
Asymptomatic Group
Symptomatic Group
26 29
11 12
Fracture No Fracture
Deformity at the distal interphalangeal joint is shown in tables V, VI and VII. TABLE V E X T E N S I O N L A G AT D.I.P. JOINT
Ext. Lag.
Asymptomatic Group
Symptomatic Group
30 41
16 13
0-10 ~ ~11 ~
TABLE VI FIXED F L E X I O N DEFORMITY AT D.I.P. JOINT
Fixed flexion deformity
Asymptomatic Group
Symptomatic Group
19 52
9 20
Present Absent
TABLE VII F L E X I O N LOSS AT D.I.P. JOINT
Flexion loss
Asymptomatic Group
Symptomatic Group
59 12
21 8
0-10 ~ >11 o
Even when the deformity was categorised more critically, zero to five degrees, six to ten degrees, eleven to nineteen degrees and more than twenty degrees, there was still no statistical difference in the two groups. Only six patients had any loss of flexion at the proximal interphalangeal joint (up to twenty degrees), four were asymptomatic and two complained of digit pain at the distal interphalangeal joint. Swan neck deformity was seen in six patients, five were asymptomatic, the other noticed pain at the distal interphalangeal joint. The Hand-- Volume 15
No. 2
1983
153
The Long Term Results o f Mallet Finger Injury A Retrospective Study o f One Hundred Cases J. G. Moss, and R. F. Steingold
DISCUSSION
Only two large reports of the incidence of long term symptoms in mallet finger injuries were found in the literature, (Hallberg, 1959; Robb, 1959), Hallberg found the incidence of symptoms to be twenty-four per cent after two to nine years but Robb quoted a figure of only nine per cent after one to three years. Both these authors found an association between symptoms and the presence of a fracture and Hallberg also found an association between residual extension lag and symptoms. However, neither author subjected his data to statistical analysis. Our study shows no statistical difference (CHI Square test) between symptomatic and asymptomatic patients when compared for delay in treatment, presence of a fracture, or residual deformity. Mallet thumb is a rate injury, (Abouna, 1968). We only saw four cases but two of these had mild pain and one cold intolerance. A larger number of thumb injuries would be needed for any definite conclusions to be made. Other studies have laid emphasis on residual extension lag (Smillie, 1937), and loss of flexion of the distal interphalangeal joint (Abouna, 1968; Hamas, 1978; Pratt, 1957; Stack, 1962), in assessing the end result of mallet finger injuries. In this series however, as many as twenty-nine of one hundred patients had symptoms three to five years after treatment, but these symptoms were not related to such residual deformities. It is suggested therefore, that, apart from cosmetic considerations, the objective measurement of residual deformity or loss of motion of either distal or proximal' interphal0ngeal joint is of no relevance to the long term prognosis of mallet finger injuries. ACKNOWLEDGEMENTS We would like to tahnk Mrs. Carol Jagger for her help with the statistics, Mrs. Kathy Green for typing and Mr. J. M. Jones, F.R.C.S., for correcting the manuscript.
REFERENCES ABOUNA, J. M. and BROWN, H. (1968). The Treatment of Mallet Finger The Results in a Series of 148 Consecutive Cases and a Review of the Literature. British Journal of Surgery 55:653-667. ALLEN, M. J. (1980). Conservative Management of Finger Tip Injuries in Adults. The Hand 12: 257-265. HALLBERG, D. and L1NDHOLM A. (1960). Subcutaneous Rupture of the Extensor Tendon Of the Distal Phalanx of the Finger: "Mallet Finger". Brief Review of the Literature and Report on 127 Cases Treated Conservatively. Acta Chirurgica Scandinavica 119: 260-267. HAMAS, R. S. HORRELL, E. D. a n d PIERRET, G. P. (1978). Treatment of mallet finger due to intra-articular fracture of the distal phalanx. The Journal of Hand Surgery, 3: 361-363. JONES, J. M., SCHENCK, R. R., CHESNEY, R. B. (1980). Digital cold intolerance following replantation. The Journal of Bone and Joint Surgery 62B: 532-533. PRATT, D. R., BUNNELL, S. and HOWARD, L. D. (1957). Mallet Finger. Classification and Methods of Treatment. American Journal of Surgery 93: 573-579. ROBB, W. A. T. (1959). The Results of Treatment of Mallet Finger. The Journal of Bone and Joint Surgery 41B: 546-549. SEGOND, P. (1880). Note sur un cas d'arrachement du point d'insertion des deux languettes phalangettienes de l'extenseur du petit doigt, par flexion forcee de la phalangette sur la phalangine Le Progres Medical 8: 534-535. SMILLIE I. S. (1937). Mallet Finger. The British Journal of Surgery 24: 439-445. STACK, H. G. (1969). Mallet Finger. The Hand 1: 83-89. STARK, H. H., BOYES, J. H. and WILSON, J. N. (1962). Mallet Finger. The Journal of Bone and Joint Surgery 44A" 1061-1068.
154
The Hand-- Volume 15
No. 2
1983
THE LONG TERM RESULTS OF M A L L E T FINGER INJURY A RETROSPECTIVE S T U D Y OF ONE H U N D R E D CASES
J. G. MOSS and R. F. STEINGOLD, Leicester SUMMARY
One hundred patients with mallet finger injuries were reviewed and examined three to five years after injury. Twenty nine patients still had symptoms consisting mainly of pain and cold intolerance. The degree of residual deformity, presence of a fracture, or delay in treatment were not related to symptoms. This common injury was first described in the literature by Segond in 1880, although the term 'mallet finger', was not coined until some years later. Previous authors have used the degree of residual deformity as a parameter for assessing the results of treatment, (Smillie, 1937; Pratt, 1957; Stack, 1962; Abouna, 1968). Very few authors have considered in any detail the long term symptoms of mallet finger, (Hallberg, 1960; Smillie, 1937). The aim of this study was to investigate the incidence of such symptoms and to assess any correlation with the digit injured, presence of a fracture, delay in treatment or residual deformity. MATERIAL AND METHODS
One hundred and seventy eight patients from the period 1977 to 1979 with a mallet finger injury were requested to attend for review. Eighty-two patients reported initially, and a further eighteen reported after a second or third letter. The remaining seventy-eight patients consisted of those who had moved from the area or were simply untraceable. The one hundred patients who returned for review were questioned and examined by one of us, (J.G.M.). The minimum length of time since injury was three years. Ninety of the patients had been treated in the same manner, using a plastic mallet splint (Stack, 1969), for six to eight weeks. The remaining ten were treated with a variety of splints and plasters. Particular attention was paid to any symptoms experienced by the patients and these were categorised into three groups: moderate symptoms, minimal symptoms and cold intolerance. Moderate symptoms denoted pain sufficiently severe to interfere with the patient's job. Minimal symptoms included slight pain, occasional reluctance to use the finger, poor grip and the finger catching on objects. Cold intolerance was a frequent symptom and therefore allocated a separate category. The degree of residual deformity was measured using a finger goniometer and compared with the normal hand. At the distal interphalangeal joint, extensor lag, fixed flexion deformity and loss o f active flexion were measured, and at the proximal interphalangeal joint, loss of active flexion and swan neck deformity. The group of symptomatic patients was then compared with the asymptomatic group with regard to the digit injured, presence of a fracture, delay in treatment and residual deformity. J. G. Moss, Western General Hospital, Crew Road, Edinburgh EH4 2XU The Hand-- Volume 15
No. 2
1983
151
The Long Term Results of Mallet Finger 1njury A Retrospective Study- of One Hundred Cases J. G. Moss, and R. F. Steingold
RESULTS Fifty-one patients were male and forty-nine female, the age range being ten years to seventy-six. The mean female age was fifty years and the mean male age, thirty-nine years. Twenty-nine of the hundred patients reviewed had symptoms; these were categorised as in Table I.
TABLE I
SYMPTOMATIC PATIENTS Symptoms
Number of patients
Pain in cold weather Minimal symptoms Moderate symptoms
13 16 2
Two patients had both cold intolerance and mild pain. Both the patients with moderate symptoms had pain in the digit which was severe enough to interfere with their job (porter and teacher). In the minimal symptom group, fourteen o f the sixteen patients experienced mild pain at the distal phalanx; six occasionally avoided using the finger because o f this. Three of the patients complained o f poor grip and two noticed the finger occasionally catching on objects. We were surprised that only two patients noticed the digit catching on objects and that one of these had an extension lag of only five degrees. Cold intolerance consisted of discomfort or pain in the distal phalanx when exposed to a cold environment and accounted for about half o f the symptomatic group. It is well recognised (Allen, 1980), but its aetiology is not clear; (Jones, 1980) suggested a loss of local axon reflex in digital replantation patients. Those patients with cold intolerance found it an annoying symptom, much more so than the patients with mild digital pain, poor grip or the finger catching on objects. Tables II, III and IV show the digit injured, the delay before the patient presented for treatment and the x-ray result; (X-rays were only available for seventyeight patients). TABLE 11 DIGIT I N J U R E D
Digit
Thumb Index Middle Ring Little
Asymptomatic Group
Symptomatic Group
1 8 22 22 18
3 6 5 5 10
It is interesting that approximately one quarter o f the fingers were symptomatic whereas three of the four thumb injuries had symptoms. 152
The Hand-- Volume 15
No. 2
1983
The Long Term Results of Mallet Finger Injury A Retrospective Study of One Hundred Cases J. G. Moss, and R. F. Steingold TABLE III D E L A Y IN TREATMENT
Delay
Asymptomatic G r o u p s
> 1 week <
Symptomatic Group
50 22
22 6
Statistically there is no difference between the two groups in this table. However there are relatively more asymptomatic patients in the group whose treatment was delayed for more than one week. This may perhaps reflect the type of patient, in that those who delay seeking treatment are less likely to complain of residual symptoms. TABLE IV X-RAY RESULT
X-ray
Asymptomatic Group
Symptomatic Group
26 29
11 12
Fracture No Fracture
Deformity at the distal interphalangeal joint is shown in tables V, VI and VII. TABLE V E X T E N S I O N L A G AT D.I.P. JOINT
Ext. Lag.
Asymptomatic Group
Symptomatic Group
30 41
16 13
0-10 ~ ~11 ~
TABLE VI FIXED F L E X I O N DEFORMITY AT D.I.P. JOINT
Fixed flexion deformity
Asymptomatic Group
Symptomatic Group
19 52
9 20
Present Absent
TABLE VII F L E X I O N LOSS AT D.I.P. JOINT
Flexion loss
Asymptomatic Group
Symptomatic Group
59 12
21 8
0-10 ~ >11 o
Even when the deformity was categorised more critically, zero to five degrees, six to ten degrees, eleven to nineteen degrees and more than twenty degrees, there was still no statistical difference in the two groups. Only six patients had any loss of flexion at the proximal interphalangeal joint (up to twenty degrees), four were asymptomatic and two complained of digit pain at the distal interphalangeal joint. Swan neck deformity was seen in six patients, five were asymptomatic, the other noticed pain at the distal interphalangeal joint. The Hand-- Volume 15
No. 2
1983
153
The Long Term Results o f Mallet Finger Injury A Retrospective Study o f One Hundred Cases J. G. Moss, and R. F. Steingold
DISCUSSION
Only two large reports of the incidence of long term symptoms in mallet finger injuries were found in the literature, (Hallberg, 1959; Robb, 1959), Hallberg found the incidence of symptoms to be twenty-four per cent after two to nine years but Robb quoted a figure of only nine per cent after one to three years. Both these authors found an association between symptoms and the presence of a fracture and Hallberg also found an association between residual extension lag and symptoms. However, neither author subjected his data to statistical analysis. Our study shows no statistical difference (CHI Square test) between symptomatic and asymptomatic patients when compared for delay in treatment, presence of a fracture, or residual deformity. Mallet thumb is a rate injury, (Abouna, 1968). We only saw four cases but two of these had mild pain and one cold intolerance. A larger number of thumb injuries would be needed for any definite conclusions to be made. Other studies have laid emphasis on residual extension lag (Smillie, 1937), and loss of flexion of the distal interphalangeal joint (Abouna, 1968; Hamas, 1978; Pratt, 1957; Stack, 1962), in assessing the end result of mallet finger injuries. In this series however, as many as twenty-nine of one hundred patients had symptoms three to five years after treatment, but these symptoms were not related to such residual deformities. It is suggested therefore, that, apart from cosmetic considerations, the objective measurement of residual deformity or loss of motion of either distal or proximal' interphal0ngeal joint is of no relevance to the long term prognosis of mallet finger injuries. ACKNOWLEDGEMENTS We would like to tahnk Mrs. Carol Jagger for her help with the statistics, Mrs. Kathy Green for typing and Mr. J. M. Jones, F.R.C.S., for correcting the manuscript.
REFERENCES ABOUNA, J. M. and BROWN, H. (1968). The Treatment of Mallet Finger The Results in a Series of 148 Consecutive Cases and a Review of the Literature. British Journal of Surgery 55:653-667. ALLEN, M. J. (1980). Conservative Management of Finger Tip Injuries in Adults. The Hand 12: 257-265. HALLBERG, D. and L1NDHOLM A. (1960). Subcutaneous Rupture of the Extensor Tendon Of the Distal Phalanx of the Finger: "Mallet Finger". Brief Review of the Literature and Report on 127 Cases Treated Conservatively. Acta Chirurgica Scandinavica 119: 260-267. HAMAS, R. S. HORRELL, E. D. a n d PIERRET, G. P. (1978). Treatment of mallet finger due to intra-articular fracture of the distal phalanx. The Journal of Hand Surgery, 3: 361-363. JONES, J. M., SCHENCK, R. R., CHESNEY, R. B. (1980). Digital cold intolerance following replantation. The Journal of Bone and Joint Surgery 62B: 532-533. PRATT, D. R., BUNNELL, S. and HOWARD, L. D. (1957). Mallet Finger. Classification and Methods of Treatment. American Journal of Surgery 93: 573-579. ROBB, W. A. T. (1959). The Results of Treatment of Mallet Finger. The Journal of Bone and Joint Surgery 41B: 546-549. SEGOND, P. (1880). Note sur un cas d'arrachement du point d'insertion des deux languettes phalangettienes de l'extenseur du petit doigt, par flexion forcee de la phalangette sur la phalangine Le Progres Medical 8: 534-535. SMILLIE I. S. (1937). Mallet Finger. The British Journal of Surgery 24: 439-445. STACK, H. G. (1969). Mallet Finger. The Hand 1: 83-89. STARK, H. H., BOYES, J. H. and WILSON, J. N. (1962). Mallet Finger. The Journal of Bone and Joint Surgery 44A" 1061-1068.
154
The Hand-- Volume 15
No. 2
1983