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Mallet Finger Injuries
Mallet Finger Injuries Charles Leinberry, MD THE PATIENT A 37-year-old orthopedic surgeon was attending a conference. During an afternoon skiing session, he fell and injured his left, nondominant hand long and ring fingers. When he returned to the evening didactic session, an image intensifier identified bony mallet injuries to the long and ring fingers. The long finger showed a bony mallet fracture involving approximately 33% of the articular surface of the distal phalanx with slight subluxation, and the ring finger involved 25% of the joint surface with no subluxation. Splints were applied, and there was spirited discussion as to the best treatment option of the mallet injuries. THE QUESTION What is the best treatment option for closed mallet finger injuries, whether bony or tendinous injuries? CURRENT OPINION Most hand surgeons believe that nonoperative care is the best option for treatment of mallet injuries in the absence of subluxation or a large intra-articular fracture.1,2 There is substantial variation in splint preferences. The appeal of surgery is limited by the pin track infection, incomplete reduction of the fracture, skin loss, and/or loss of fixation. THE EVIDENCE Studies comparing splints Kinninmouth and Holburn3 reported a prospective study that randomized 54 patients to either a perforated splint or a Stack splint (prefabricated, molded polyethylene splint). The perforated splint was better From the Rothman Institute, Thomas Jefferson University Hospital, Department of Orthopaedic Surgery, Philadelphia, PA. Received for publication June 18, 2009; accepted in revised form June 18, 2009. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Charles Leinberry, MD, Rothman Institute, Thomas Jefferson University Hospital, Department of Orthopaedic Surgery, 925 Chestnut Street, Philadelphia, PA 19107; e-mail: [email protected]. 0363-5023/09/34A09-0021$36.00/0 doi:10.1016/j.jhsa.2009.06.018
tolerated and was associated with greater compliance but needed to be custom molded by a therapist. Maitra and Dorani4 compared use of aluminumalloy malleable splints versus the Stack splint. There were more skin complications with the Stack splint, but the groups had similar outcomes. Warren et al.5 compared use of the Abouna splint6 (rubber-coated wire splint) versus the Stack splint. The Abouna splint had skin issues and lower patient satisfaction but similar outcomes compared with those of the Stack splint. Splint versus surgery Niechajev2 performed a 10-year, nonrandomized prospective cohort study involving 150 patients with mallet fingers. Eighty-two were tendon injuries and 68 were fractures. Patients were followed up for an average of 3 years. All 92 patients with tendon rupture or a small nonarticular avulsion (chip) fracture had splint treatment. Among the 43 patients with articular fractures, 26 had surgery, 12 were splinted, and 5 were not immobilized. Nonsurgical treatment consisted of an aluminum splint placed either dorsally or volarly, whereas surgery was performed by pinning and open repair of the fracture with a pull-out wire technique. The authors concluded that surgery should be considered for injuries with subluxation of the distal phalanx1 and small fragments including more than a third of the joint surface and with a diastasis larger than 3 mm.2 Stern and Kastrup7 reviewed 123 mallet injuries retrospectively. There were 45 intra-articular fractures, 37 avulsion or chip fractures, and 39 tendon injuries. Seventy-eight were treated with splints, 39 had surgery, and 6 had both. The authors noted a complication rate of 53% in the surgically treated patients (of whom 76% had long-term complications) including infections (20%), permanent nail deformities (18%), joint incongruity (18%), fixation failure (13%), and bony prominence (11%). The conclusion was that splinting is preferred for treatment of nearly all mallet finger injuries. Wehbe and Schneider8 retrospectively reviewed 160 patients with mallet injuries, including 44 with fracture (28%). Twenty-one of the patients with fracture were followed up for at least 6 months with a mean of just
© Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1715
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
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MALLET FINGER INJURIES
Evidence-Based Medicine
over 3 years. Among the 9 surgically treated patients, 2 had complications: one was a loss of reduction and the second was an inadvertent pull-out button removal. Degenerative changes were comparable in the surgical and nonsurgical treatment groups, and the authors concluded that splinting is a safe and reliable treatment for most mallet injuries, whether bony or tendinous. Lubahn9 reported a prospective cohort of 30 mallet fractures treated with either surgery or splinting. Eleven patients with either joint subluxation or a fracture involving more than a third of the articular surface were treated surgically, and the remaining 19 patients were treated with splints. At very short follow-up, it was argued that open reduction and use of smaller K-wires provided a cosmetically and functionally superior result in selected cases. Auchincloss10 prospectively randomized 50 consecutive patients with mallet injuries to either closed pinning or splint treatment. There were 3 skin irritations with splinting and 2 pin track infections. The results were comparable for surgical and nonsurgical treatment, but the author inferred that those treated in the second week may do better with surgery. Geyman et al.11 attempted a meta-analysis of studies published from 1966 through 1998 but found only 1 randomized clinical trial. Based on a pooled literature review, they concluded that nonsurgical splint treatment is acceptable for most mallet injuries including fractures up to one third of the articular surface. Extensor lag up to 30% is well tolerated in most patients, and surgery should be used in complex or recurrent injuries. A more recent meta-analysis by Handoll and Voghela12 identified 4 articles that met the inclusion criteria (all reviewed above): 3 involving splint treatment3,8,9 and 1 comparing splinting and K-wire fixation.12 The authors concluded that there is insufficient evidence to determine which splint type is the best, but that the splint must be strong enough to withstand everyday use. Also, strict adherence to the splint protocol is important. Concerning surgery, there was insufficient evidence to determine when surgery is indicated. Relevant to the patient under consideration, one article by O’Farrell et al.13 describes the treatment of 3 surgeons who sustained closed mallet injuries through recreational activities. None preferred surgery, but they all wanted to continue to operate. Therefore they were managed with a sterile intraoperative splint system that allowed them to maintain a full surgical schedule. The authors stated they had been using this technique for more than 20 years in treating surgeons and dentists with good results.
SHORTCOMINGS OF THE EVIDENCE AND DIRECTIONS FOR FUTURE RESEARCH Although a great deal of original data have been published regarding mallet injuries, most of the data consists of uncontrolled studies. Given that mallet injuries are common, it should be possible to execute several prospective randomized studies comparing various aspects of the management of these injuries, surgical versus nonoperative treatment in particular. In particular, percutaneous pinning and limited open techniques merit study for bony mallet injuries. MY CURRENT CONCEPTS According to a review of current literature, best evidence supports splint treatment of the majority of mallet injuries. The type of splint is not as important as patient compliance. Surgical treatment is only considered when joint subluxation is present or a large displaced articular fracture fragment (greater than one third of the joint) is present. Complications must be carefully considered when surgery is contemplated. Regardless of treatment choice, patients must understand that they are likely to have a slight extensor lag and possibly a prominent bump on the dorsum of the finger after treatment. After long discussion with many of the hand surgeons at the meeting, it was clear that the majority favored splint treatment. However, due to pain, the inability of a splint to prevent subluxation of the long finger fracture, and the fact that the surgeon thought pinning was the best option to continue to maintain his surgical schedule, he elected to have both fractures percutaneously pinned with 1.4 mm (0.045 in.) Kwires. The pins were cut off under the skin, and splints were used for daily activities, except when performing surgery. A full surgery schedule was maintained without difficulty. The pins were removed 8 weeks after surgery, and the patient is currently working on regaining range of motion. REFERENCES 1. Jablecki J, Syrko M. Zone 1 extensor tendon lesions: current treatment methods and a review of the literature. Orthop Traumatol Rehabil 2007;9:52– 62. 2. Niechajev IA. Conservative and operative treatment of mallet finger. Plast Reconstr Surg 2005;76:580 –585. 3. Kinninmonth AW, Holburn F. A comparative controlled trial of a new perforated splint in treatment of mallet finger. J Hand Surg 1986;11B:261–262. 4. Maitra A, Dorani B. The conservative treatment of mallet finger with a simple splint: a case report. Arch Emerg Med 1993;10: 244 –248. 5. Warren RA, Norris SH, Ferguson DG. Mallet finger: a trial of two splints. J Hand Surg 1988;13B:151–153.
JHS 䉬 Vol A, November
6. Abuna JM, Braun H. The treatment of mallet finger. The results in a series of 148 consecutive cases and a review of the literature. Br J Surg 1968;55:653– 667. 7. Stern PJ, Kastrup JJ. Complications and prognosis of treatment of mallet finger. J Hand Surg 1988;13A:329 –334. 8. Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg 1984;66A:658 – 669. 9. Lubahn JD. Mallet finger fractures: a comparison of open and closed techniques. J Hand Surg 1989;14A:394 –396.
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10. Auchincloss JM. Mallet finger injuries: a prospective, controlled trial of internal and external splintage. Hand 1982;14:168 –173. 11. Geyman JP, Fink K, Sullivan SD. Conservative versus surgical treatment of mallet finger: a pooled qualitative literature evaluation. J Am Board Family Practice 1998;11:382–390. 12. Handoll Helen HG, Voghela M. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev 2009;(1). 13. O’Farrell D, Gilbert J, Goldner R. Treatment for the mallet finger injuries of surgeons. J Hand Ther 1994;7:258 –259.
JHS 䉬 Vol A, November
Evidence-Based Medicine
MALLET FINGER INJURIES
tolerated and was associated with greater compliance but needed to be custom molded by a therapist. Maitra and Dorani4 compared use of aluminumalloy malleable splints versus the Stack splint. There were more skin complications with the Stack splint, but the groups had similar outcomes. Warren et al.5 compared use of the Abouna splint6 (rubber-coated wire splint) versus the Stack splint. The Abouna splint had skin issues and lower patient satisfaction but similar outcomes compared with those of the Stack splint. Splint versus surgery Niechajev2 performed a 10-year, nonrandomized prospective cohort study involving 150 patients with mallet fingers. Eighty-two were tendon injuries and 68 were fractures. Patients were followed up for an average of 3 years. All 92 patients with tendon rupture or a small nonarticular avulsion (chip) fracture had splint treatment. Among the 43 patients with articular fractures, 26 had surgery, 12 were splinted, and 5 were not immobilized. Nonsurgical treatment consisted of an aluminum splint placed either dorsally or volarly, whereas surgery was performed by pinning and open repair of the fracture with a pull-out wire technique. The authors concluded that surgery should be considered for injuries with subluxation of the distal phalanx1 and small fragments including more than a third of the joint surface and with a diastasis larger than 3 mm.2 Stern and Kastrup7 reviewed 123 mallet injuries retrospectively. There were 45 intra-articular fractures, 37 avulsion or chip fractures, and 39 tendon injuries. Seventy-eight were treated with splints, 39 had surgery, and 6 had both. The authors noted a complication rate of 53% in the surgically treated patients (of whom 76% had long-term complications) including infections (20%), permanent nail deformities (18%), joint incongruity (18%), fixation failure (13%), and bony prominence (11%). The conclusion was that splinting is preferred for treatment of nearly all mallet finger injuries. Wehbe and Schneider8 retrospectively reviewed 160 patients with mallet injuries, including 44 with fracture (28%). Twenty-one of the patients with fracture were followed up for at least 6 months with a mean of just
© Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1715
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
1716
MALLET FINGER INJURIES
Evidence-Based Medicine
over 3 years. Among the 9 surgically treated patients, 2 had complications: one was a loss of reduction and the second was an inadvertent pull-out button removal. Degenerative changes were comparable in the surgical and nonsurgical treatment groups, and the authors concluded that splinting is a safe and reliable treatment for most mallet injuries, whether bony or tendinous. Lubahn9 reported a prospective cohort of 30 mallet fractures treated with either surgery or splinting. Eleven patients with either joint subluxation or a fracture involving more than a third of the articular surface were treated surgically, and the remaining 19 patients were treated with splints. At very short follow-up, it was argued that open reduction and use of smaller K-wires provided a cosmetically and functionally superior result in selected cases. Auchincloss10 prospectively randomized 50 consecutive patients with mallet injuries to either closed pinning or splint treatment. There were 3 skin irritations with splinting and 2 pin track infections. The results were comparable for surgical and nonsurgical treatment, but the author inferred that those treated in the second week may do better with surgery. Geyman et al.11 attempted a meta-analysis of studies published from 1966 through 1998 but found only 1 randomized clinical trial. Based on a pooled literature review, they concluded that nonsurgical splint treatment is acceptable for most mallet injuries including fractures up to one third of the articular surface. Extensor lag up to 30% is well tolerated in most patients, and surgery should be used in complex or recurrent injuries. A more recent meta-analysis by Handoll and Voghela12 identified 4 articles that met the inclusion criteria (all reviewed above): 3 involving splint treatment3,8,9 and 1 comparing splinting and K-wire fixation.12 The authors concluded that there is insufficient evidence to determine which splint type is the best, but that the splint must be strong enough to withstand everyday use. Also, strict adherence to the splint protocol is important. Concerning surgery, there was insufficient evidence to determine when surgery is indicated. Relevant to the patient under consideration, one article by O’Farrell et al.13 describes the treatment of 3 surgeons who sustained closed mallet injuries through recreational activities. None preferred surgery, but they all wanted to continue to operate. Therefore they were managed with a sterile intraoperative splint system that allowed them to maintain a full surgical schedule. The authors stated they had been using this technique for more than 20 years in treating surgeons and dentists with good results.
SHORTCOMINGS OF THE EVIDENCE AND DIRECTIONS FOR FUTURE RESEARCH Although a great deal of original data have been published regarding mallet injuries, most of the data consists of uncontrolled studies. Given that mallet injuries are common, it should be possible to execute several prospective randomized studies comparing various aspects of the management of these injuries, surgical versus nonoperative treatment in particular. In particular, percutaneous pinning and limited open techniques merit study for bony mallet injuries. MY CURRENT CONCEPTS According to a review of current literature, best evidence supports splint treatment of the majority of mallet injuries. The type of splint is not as important as patient compliance. Surgical treatment is only considered when joint subluxation is present or a large displaced articular fracture fragment (greater than one third of the joint) is present. Complications must be carefully considered when surgery is contemplated. Regardless of treatment choice, patients must understand that they are likely to have a slight extensor lag and possibly a prominent bump on the dorsum of the finger after treatment. After long discussion with many of the hand surgeons at the meeting, it was clear that the majority favored splint treatment. However, due to pain, the inability of a splint to prevent subluxation of the long finger fracture, and the fact that the surgeon thought pinning was the best option to continue to maintain his surgical schedule, he elected to have both fractures percutaneously pinned with 1.4 mm (0.045 in.) Kwires. The pins were cut off under the skin, and splints were used for daily activities, except when performing surgery. A full surgery schedule was maintained without difficulty. The pins were removed 8 weeks after surgery, and the patient is currently working on regaining range of motion. REFERENCES 1. Jablecki J, Syrko M. Zone 1 extensor tendon lesions: current treatment methods and a review of the literature. Orthop Traumatol Rehabil 2007;9:52– 62. 2. Niechajev IA. Conservative and operative treatment of mallet finger. Plast Reconstr Surg 2005;76:580 –585. 3. Kinninmonth AW, Holburn F. A comparative controlled trial of a new perforated splint in treatment of mallet finger. J Hand Surg 1986;11B:261–262. 4. Maitra A, Dorani B. The conservative treatment of mallet finger with a simple splint: a case report. Arch Emerg Med 1993;10: 244 –248. 5. Warren RA, Norris SH, Ferguson DG. Mallet finger: a trial of two splints. J Hand Surg 1988;13B:151–153.
JHS 䉬 Vol A, November
6. Abuna JM, Braun H. The treatment of mallet finger. The results in a series of 148 consecutive cases and a review of the literature. Br J Surg 1968;55:653– 667. 7. Stern PJ, Kastrup JJ. Complications and prognosis of treatment of mallet finger. J Hand Surg 1988;13A:329 –334. 8. Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg 1984;66A:658 – 669. 9. Lubahn JD. Mallet finger fractures: a comparison of open and closed techniques. J Hand Surg 1989;14A:394 –396.
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10. Auchincloss JM. Mallet finger injuries: a prospective, controlled trial of internal and external splintage. Hand 1982;14:168 –173. 11. Geyman JP, Fink K, Sullivan SD. Conservative versus surgical treatment of mallet finger: a pooled qualitative literature evaluation. J Am Board Family Practice 1998;11:382–390. 12. Handoll Helen HG, Voghela M. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev 2009;(1). 13. O’Farrell D, Gilbert J, Goldner R. Treatment for the mallet finger injuries of surgeons. J Hand Ther 1994;7:258 –259.
JHS 䉬 Vol A, November
Evidence-Based Medicine
MALLET FINGER INJURIES