- Email: [email protected]
A novel way of treating mallet finger injuries
Journal of Hand Therapy xxx (2014) 1e4
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Practice Forum
A novel way of treating mallet finger injuries Dershnee Devan BOcc (UKZN), Dip in Hand Therapy (UP) * Occupational Therapy Department, University of Witwatersrand, 7 York Rd., Parktown, South Africa
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 January 2014 Accepted 17 February 2014 Available online xxx
This article proposes a novel approach to treat mallet finger injuries conservatively. Mallet finger injuries often require long periods of immobilization to ensure that the distal interphalangeal joint regains full extension. The proposed method uses kinesiotape and orthotic intervention as well as a reduced period of immobilization. This allows for earlier mobilization of the distal interphalangeal joint. Standard treatment protocols following a mallet finger injury involve lengthy periods of immobilization in an effort to ensure the terminal extensor tendon is able to maintain the distal interphalangeal joint in extension. This author describes a technique that utilizes a combination of an orthosis and kinesiotape, thereby creating a treatment protocol that shortens the immobilization phase for these patients e Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Mallet finger Kinesiotape Rehabilitation
Introduction
Treatment
Mallet finger injuries are commonly sustained during sport activities and minor incidents. Various orthotic interventions and techniques have been researched in the field of mallet finger rehabilitation.1e4 A study conducted in 20111 concluded that the orthosis had to be robust, not cause complications, and that favorable outcomes correlated with compliance with orthotic intervention. Patient compliance in mallet finger injuries is often problematic due to the discomfort of wearing an orthosis continuously and the complicated procedure of orthosis application and removal.3 This is due to the danger of extensor tendon compromise if the orthosis is not removed in a particular manner to ensure the distal interphalangeal joint (DIPJ) remains extended at all times. The treatment method proposed in this manuscript was first devised by the Kinesiotaping (KT) Association and published in 2003,5 and recommended for use in mallet finger injuries not requiring surgery or for use post surgically or post orthotic intervention. The technique was advocated to limit flexion of the distal interphalangeal joint. This author adapted the original method by the KT Association by excluding DIPJ flexion as a step in the technique. This adaptation was done to avoid further compromise of the injured tendon. The protocol for application and mobilization was developed subsequently.
The treatment method uses elastic taping with a thermoplastic orthosis for four weeks of DIPJ immobilization. Graded protective mobilization is started at week 4 with the elastic taping in situ for a further two weeks. During this time, a night orthosis is worn. At week 6, the taping is discontinued while the active range of motion and light activities of daily living are continued. Heavy activities and sport are resumed after week 8 if full active range of motion is attained. The following steps are followed when applying the elastic tape to the affected finger. Please note that any kind of elastic tape that is similar to kinesiotape can be used. It is not necessary to use kinesiotape specifically; however, the author has used kinesiotape with all of the patients treated.
* Corresponding author. Tel.: þ27 824179391, þ27 117173701. E-mail addresses: [email protected], [email protected].
Step 1 (refer to Fig. 1) Cut one piece of elastic tape measuring 15e20 cm by 1.5 cm and two pieces measuring 5 cm by 1.5 cm. The length of the longer piece is usually 1.5 cm by 15 cm. If working with a larger hand, increase the length to 1.5 cm by 20 cm. Step 2 (refer to Fig. 2) Remove the backing from the tape and apply the end of first piece of elastic tape (1.5 cm by 15 cm) to the volar aspect of the finger. Ensure that the end of the tape (1.5 cm by 15 cm) is secured midway between the proximal and distal interphalangeal joints on the volar surface. Allow this piece to hang while applying the smaller piece (5 cm by 1.5 cm) of tape securing the lower end of the longer piece on the volar aspect as shown in Fig. 2. Step 3 (refer to Fig. 3)
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.02.005
2
D. Devan / Journal of Hand Therapy xxx (2014) 1e4
Fig. 3. Positioning of finger and application of tape dorsally.
Fig. 1. Three pieces of elastic tape.
Turn the hand so that the finger rests on the table. Remove the backing from the middle section of the tape (1.5 cm by 15 cm). Hold the distal end of the tape in one hand while positioning the finger in 20 e30 degrees of hyperextension at the metacarpal phalangeal joint. Keep the distal and proximal interphalangeal joints extended at all times.
Fig. 2. Application of the elastic tape to the volar aspect of the finger.
Apply the elastic tape to the dorsum of the finger in line with the extensor tendon. Step 4 (refer to Fig. 4) The tape should extend to distal crease of the wrist. Ensure that the tape is secured by rubbing against the tape once it is applied to the skin on both volar and dorsal surfaces. Step 5 (refer to Fig. 5) Apply the second smaller piece of the tape to anchor the tape over the dorsal aspect of the wrist. The patient must be taught how to reapply the elastic tape every 3e5 days. Step 6 (refer to Figs. 5 and 6) A custom made thermoplastic orthosis which immobilizes the affected DIPJ and allows full range of motion of the PIPJ is applied. The patient should be educated on the necessity of wearing the thermoplastic orthosis at all times, excluding self care, for the first 4 weeks, then at night only for a further 2e4 weeks depending on the progress. Clinical data The author has been collecting data on 16 patients treated with the technique described. Informed consent was obtained and the rights of all participants were protected.
Fig. 4. Application of the elastic tape to the dorsum of the finger.
D. Devan / Journal of Hand Therapy xxx (2014) 1e4
3
Fig. 7. Percentage of compliance by participants (Devan7).
Fig. 5. Application of orthosis.
Results showed good compliance (14/16 patients; 88%) with the treatment modality, follow up, and subsequent discharge (Fig. 7). The results showed good range of motion in 4 weeks with limited evidence of extensor tendon lag at 12 weeks follow up (Table 1). Discussion The rate of compliance could be related to the fact that removal of the orthosis during self-care was simplified as the tape holds the DIPJ in extension when the orthosis is removed. Additionally, another factor impacting compliance may be due to the fact that period of immobilization was shorter. The usual rehabilitation protocol dictates 6e8 weeks immobilization1e4,6; however, this protocol uses 4 weeks of immobilization. Previous research has shown that compliance and stiffness are often encountered in rehabilitation of mallet finger injuries.1e4 The range of motion post treatment was good and this could be attributed to early protected mobilization which resulted in less
stiffness. Some of the mallet injuries could also have been caused by partial tears which would have influenced the outcome positively, as opposed to complete lacerations or avulsions of the extensor tendon. The majority of injuries treated were closed injuries and there was not sufficient information available on the extent of tendon injury at the time of referral. The proposed method could be adapted further by restricting the length of tape to the finger length and applying a higher stretch to the tape. This would only be utilized during immobilization to prevent distal interphalangeal joint flexion, but would simplify the taping method and possibly increase patient compliance further. There is a definite indication that elastic taping in combination with orthotic intervention could be the answer to the problems therapists experience in rehabilitation of the mallet finger with compliance and stiffness. However a large scale prospective, randomized controlled trial is indicated to determine the clinical efficacy of the proposed protocol. Conclusion The clinical efficacy of the proposed method of elastic taping for the treatment of mallet finger injuries remains to be tested vigorously. It may prove to be a novel solution to an often frustrating and prolonged rehabilitation process. Table 1 Results of pilot study on 16 patients Patient Systemic conditions/late Severity of injury presentation
Age Range of motion on discharge
1 2 3
Closed Closed Closed
20 27 45
0 e65 Noncompliant 0 e65
Closed Closed
13 99
0 e60 10 extensor lag
Closed, avulsion of extensor tendon Closed, k wire fixation Closed Closed Closed, k wire Closed Closed, k wire Closed Closed, k wire Closed Closed, fracture
29
Noncompliant
27
0 e50
57 41 40 37 15 23 49 38 12
5 extensor lag 15 extensor lag 0 e50 0 e55 0 e65 0 e60 0 e55 0 e50 0 e50
6
None None Late presentation 6 wks post injury None Prior malignancy and chemotherapy None
7
None
8 9 10 11 12 13 14 15 16
Diabetes None None None None None None None None
4 5
Fig. 6. Completed technique.
4
D. Devan / Journal of Hand Therapy xxx (2014) 1e4
Declaration
References
1. The results of this study were presented at the International Federation of Societies for Hand Therapy (IFSHT) 2013 congress in New Delhi. All results and figures displaying the results are taken from the original poster which was prepared by the author for that congress. 2. The original method of taping of a mallet finger injury was proposed by the Kinesiotaping Association in the manual titled “Clinical therapeutic applications of the kinesiotaping method” published in 2003.5 The proposed method has been adapted by the author to exclude the step of DIPJ flexion. 3. The author has no financial interest to declare in relation to the content of this article and has no relationship with the kinesiotaping association.
1. O’Brien LJ, Bailey MJ. Single blind, prospective, randomized controlled trial comparing dorsal aluminum and custom thermoplastic splints to stack splint for acute mallet finger. Arch Phys Med Rehabil. 2011;92(2):191e198. 2. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev. 2004;3:CD004574. 3. Smit JM, Beets MR, Zeebregts CJ, Rood A, Welters CF. Treatment options for mallet finger: a review. Plast Reconstr Surg. 2010 Nov;126(5):1624e1629. 4. Pike J, Mulpuri K, Metzger M, Ng G, Wells N, Goetz T. Blinded, prospective randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. J Hand Surg Am. 2010 Apr;35(4):580e588. 5. Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the Kinesiotaping Method. 2nd ed. Tokyo, Japan: Ken Ikai Co. Ltd; 2003:127. 6. Leggit JC, Meko CJ. Acute finger injuries. Part 1: tendons and ligaments. Am Fam Physician. 2006 Mar 1;73(5):810e816. 7. Devan D. Preliminary investigation to determine the efficacy of elastic taping in the treatment of mallet finger injuries. Poster Presentation IFSHT 2013, New Delhi.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Practice Forum
A novel way of treating mallet finger injuries Dershnee Devan BOcc (UKZN), Dip in Hand Therapy (UP) * Occupational Therapy Department, University of Witwatersrand, 7 York Rd., Parktown, South Africa
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 January 2014 Accepted 17 February 2014 Available online xxx
This article proposes a novel approach to treat mallet finger injuries conservatively. Mallet finger injuries often require long periods of immobilization to ensure that the distal interphalangeal joint regains full extension. The proposed method uses kinesiotape and orthotic intervention as well as a reduced period of immobilization. This allows for earlier mobilization of the distal interphalangeal joint. Standard treatment protocols following a mallet finger injury involve lengthy periods of immobilization in an effort to ensure the terminal extensor tendon is able to maintain the distal interphalangeal joint in extension. This author describes a technique that utilizes a combination of an orthosis and kinesiotape, thereby creating a treatment protocol that shortens the immobilization phase for these patients e Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Mallet finger Kinesiotape Rehabilitation
Introduction
Treatment
Mallet finger injuries are commonly sustained during sport activities and minor incidents. Various orthotic interventions and techniques have been researched in the field of mallet finger rehabilitation.1e4 A study conducted in 20111 concluded that the orthosis had to be robust, not cause complications, and that favorable outcomes correlated with compliance with orthotic intervention. Patient compliance in mallet finger injuries is often problematic due to the discomfort of wearing an orthosis continuously and the complicated procedure of orthosis application and removal.3 This is due to the danger of extensor tendon compromise if the orthosis is not removed in a particular manner to ensure the distal interphalangeal joint (DIPJ) remains extended at all times. The treatment method proposed in this manuscript was first devised by the Kinesiotaping (KT) Association and published in 2003,5 and recommended for use in mallet finger injuries not requiring surgery or for use post surgically or post orthotic intervention. The technique was advocated to limit flexion of the distal interphalangeal joint. This author adapted the original method by the KT Association by excluding DIPJ flexion as a step in the technique. This adaptation was done to avoid further compromise of the injured tendon. The protocol for application and mobilization was developed subsequently.
The treatment method uses elastic taping with a thermoplastic orthosis for four weeks of DIPJ immobilization. Graded protective mobilization is started at week 4 with the elastic taping in situ for a further two weeks. During this time, a night orthosis is worn. At week 6, the taping is discontinued while the active range of motion and light activities of daily living are continued. Heavy activities and sport are resumed after week 8 if full active range of motion is attained. The following steps are followed when applying the elastic tape to the affected finger. Please note that any kind of elastic tape that is similar to kinesiotape can be used. It is not necessary to use kinesiotape specifically; however, the author has used kinesiotape with all of the patients treated.
* Corresponding author. Tel.: þ27 824179391, þ27 117173701. E-mail addresses: [email protected], [email protected].
Step 1 (refer to Fig. 1) Cut one piece of elastic tape measuring 15e20 cm by 1.5 cm and two pieces measuring 5 cm by 1.5 cm. The length of the longer piece is usually 1.5 cm by 15 cm. If working with a larger hand, increase the length to 1.5 cm by 20 cm. Step 2 (refer to Fig. 2) Remove the backing from the tape and apply the end of first piece of elastic tape (1.5 cm by 15 cm) to the volar aspect of the finger. Ensure that the end of the tape (1.5 cm by 15 cm) is secured midway between the proximal and distal interphalangeal joints on the volar surface. Allow this piece to hang while applying the smaller piece (5 cm by 1.5 cm) of tape securing the lower end of the longer piece on the volar aspect as shown in Fig. 2. Step 3 (refer to Fig. 3)
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.02.005
2
D. Devan / Journal of Hand Therapy xxx (2014) 1e4
Fig. 3. Positioning of finger and application of tape dorsally.
Fig. 1. Three pieces of elastic tape.
Turn the hand so that the finger rests on the table. Remove the backing from the middle section of the tape (1.5 cm by 15 cm). Hold the distal end of the tape in one hand while positioning the finger in 20 e30 degrees of hyperextension at the metacarpal phalangeal joint. Keep the distal and proximal interphalangeal joints extended at all times.
Fig. 2. Application of the elastic tape to the volar aspect of the finger.
Apply the elastic tape to the dorsum of the finger in line with the extensor tendon. Step 4 (refer to Fig. 4) The tape should extend to distal crease of the wrist. Ensure that the tape is secured by rubbing against the tape once it is applied to the skin on both volar and dorsal surfaces. Step 5 (refer to Fig. 5) Apply the second smaller piece of the tape to anchor the tape over the dorsal aspect of the wrist. The patient must be taught how to reapply the elastic tape every 3e5 days. Step 6 (refer to Figs. 5 and 6) A custom made thermoplastic orthosis which immobilizes the affected DIPJ and allows full range of motion of the PIPJ is applied. The patient should be educated on the necessity of wearing the thermoplastic orthosis at all times, excluding self care, for the first 4 weeks, then at night only for a further 2e4 weeks depending on the progress. Clinical data The author has been collecting data on 16 patients treated with the technique described. Informed consent was obtained and the rights of all participants were protected.
Fig. 4. Application of the elastic tape to the dorsum of the finger.
D. Devan / Journal of Hand Therapy xxx (2014) 1e4
3
Fig. 7. Percentage of compliance by participants (Devan7).
Fig. 5. Application of orthosis.
Results showed good compliance (14/16 patients; 88%) with the treatment modality, follow up, and subsequent discharge (Fig. 7). The results showed good range of motion in 4 weeks with limited evidence of extensor tendon lag at 12 weeks follow up (Table 1). Discussion The rate of compliance could be related to the fact that removal of the orthosis during self-care was simplified as the tape holds the DIPJ in extension when the orthosis is removed. Additionally, another factor impacting compliance may be due to the fact that period of immobilization was shorter. The usual rehabilitation protocol dictates 6e8 weeks immobilization1e4,6; however, this protocol uses 4 weeks of immobilization. Previous research has shown that compliance and stiffness are often encountered in rehabilitation of mallet finger injuries.1e4 The range of motion post treatment was good and this could be attributed to early protected mobilization which resulted in less
stiffness. Some of the mallet injuries could also have been caused by partial tears which would have influenced the outcome positively, as opposed to complete lacerations or avulsions of the extensor tendon. The majority of injuries treated were closed injuries and there was not sufficient information available on the extent of tendon injury at the time of referral. The proposed method could be adapted further by restricting the length of tape to the finger length and applying a higher stretch to the tape. This would only be utilized during immobilization to prevent distal interphalangeal joint flexion, but would simplify the taping method and possibly increase patient compliance further. There is a definite indication that elastic taping in combination with orthotic intervention could be the answer to the problems therapists experience in rehabilitation of the mallet finger with compliance and stiffness. However a large scale prospective, randomized controlled trial is indicated to determine the clinical efficacy of the proposed protocol. Conclusion The clinical efficacy of the proposed method of elastic taping for the treatment of mallet finger injuries remains to be tested vigorously. It may prove to be a novel solution to an often frustrating and prolonged rehabilitation process. Table 1 Results of pilot study on 16 patients Patient Systemic conditions/late Severity of injury presentation
Age Range of motion on discharge
1 2 3
Closed Closed Closed
20 27 45
0 e65 Noncompliant 0 e65
Closed Closed
13 99
0 e60 10 extensor lag
Closed, avulsion of extensor tendon Closed, k wire fixation Closed Closed Closed, k wire Closed Closed, k wire Closed Closed, k wire Closed Closed, fracture
29
Noncompliant
27
0 e50
57 41 40 37 15 23 49 38 12
5 extensor lag 15 extensor lag 0 e50 0 e55 0 e65 0 e60 0 e55 0 e50 0 e50
6
None None Late presentation 6 wks post injury None Prior malignancy and chemotherapy None
7
None
8 9 10 11 12 13 14 15 16
Diabetes None None None None None None None None
4 5
Fig. 6. Completed technique.
4
D. Devan / Journal of Hand Therapy xxx (2014) 1e4
Declaration
References
1. The results of this study were presented at the International Federation of Societies for Hand Therapy (IFSHT) 2013 congress in New Delhi. All results and figures displaying the results are taken from the original poster which was prepared by the author for that congress. 2. The original method of taping of a mallet finger injury was proposed by the Kinesiotaping Association in the manual titled “Clinical therapeutic applications of the kinesiotaping method” published in 2003.5 The proposed method has been adapted by the author to exclude the step of DIPJ flexion. 3. The author has no financial interest to declare in relation to the content of this article and has no relationship with the kinesiotaping association.
1. O’Brien LJ, Bailey MJ. Single blind, prospective, randomized controlled trial comparing dorsal aluminum and custom thermoplastic splints to stack splint for acute mallet finger. Arch Phys Med Rehabil. 2011;92(2):191e198. 2. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev. 2004;3:CD004574. 3. Smit JM, Beets MR, Zeebregts CJ, Rood A, Welters CF. Treatment options for mallet finger: a review. Plast Reconstr Surg. 2010 Nov;126(5):1624e1629. 4. Pike J, Mulpuri K, Metzger M, Ng G, Wells N, Goetz T. Blinded, prospective randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. J Hand Surg Am. 2010 Apr;35(4):580e588. 5. Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the Kinesiotaping Method. 2nd ed. Tokyo, Japan: Ken Ikai Co. Ltd; 2003:127. 6. Leggit JC, Meko CJ. Acute finger injuries. Part 1: tendons and ligaments. Am Fam Physician. 2006 Mar 1;73(5):810e816. 7. Devan D. Preliminary investigation to determine the efficacy of elastic taping in the treatment of mallet finger injuries. Poster Presentation IFSHT 2013, New Delhi.