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Dedo en martillo
Mallet finger causes fingertip drooping after extensor tendon injury; splinting is key, surgery occasionally needed.
Qué está sintiendo¶
En el caso de un dedo en martillo, la última articulación del dedo queda doblada hacia abajo y no puede enderezar la punta del dedo por sí mismo. El dedo puede parecer doblado en la últa articulación, la más cercana a la uña. Esta lesión se produce cuando el tendón encargado de enderezar esa articulación se desgarra o se separa, a veces arrastrando consigo un pequeño fragmento óseo.
La última articulación suele ser sensible al tacto y puede presentar hinchazón o hematomas, especialmente en los primeros días tras la lesión. Intentar enderezar la punta del dedo, agarrar una pelota o golpear el dedo intensifican el dolor. Mantener el dedo inmóvil, sujeto con una férula, suele aliviar los síntomas.
En la vida cotidiana, la punta doblada dificulta las tareas delicadas. Recoger monedas, abrochar botones pequeños, escribir a máquina o sostener un bolígrafo resultan complicados, pues la punta del dedo no se endereza. Los deportes con pelota son una causa frecuente de esta lesión; a menudo, un dedo atrapado durante el juego es el desencadenante.
En algunos casos, aparece un segundo problema más arriba del dedo. Cuando la última articulación queda doblada, la articulación intermedia puede empezar a enderezarse en exceso o a doblarse hacia atrás. Si nota esto, indíquelo, pues modifica el tratamiento a seguir.
Un factor es más importante que casi cualquier otro: el momento en que se actúa. Acudir al médico y colocar una férula a tiempo, preferiblemente dentro de las dos semanas posteriores a la lesión, maximiza las posibilidades de recuperar una punta de dedo recta y funcional. La demora puede provocar rigidez permanente o una mala alineación articular. Aun así, si el dedo lleva tiempo doblado, merece ser evaluado, pues existen opciones de tratamiento para casos sin intervención previa.
No es necesario adivinar la gravedad de la lesión. Si la punta del dedo queda doblada tras un golpe, eso basta para solicitar una evaluación, de modo que se pueda aplicar la férula o el tratamiento adecuado antes de que la articulación sufra cambios irreversibles.
¿Qué está ocurriendo realmente?¶
La punta del dedo se endereza gracias a un delgado cordón de tendón, una especie de cuerda formada por fibras resistentes, que recorre la parte dorsal del dedo y se fija a su último hueso. En el caso de un dedo en martillo, ese cordón se rompe o se desprende de su anclaje, a veces arrastrando consigo un pequeño fragmento óseo. La articulación distal ya no puede enderezarse desde la parte dorsal; por eso, el tendón encargado de flexionar la articulación la tira hacia abajo, dejándola en una posición curvada que la persona no puede corregir por sí misma.
La mayoría de estas lesiones se producen por una fuerza de compresión: por ejemplo, cuando la punta del dedo queda atrapada en una sábana o cuando un balón golpea un dedo extendido, provocando una flexión brusca de la articulación distal. Con menos frecuencia, una fuerza excesiva que lo estira demasiado rompe un fragmento óseo más grande en la base del último hueso. Cuando dicho fragmento afecta a un tercio o más de la superficie articular, generalmente se recomienda la cirugía. También se recomienda la cirugía cuando el último hueso se desplaza fuera de su posición hacia la palma, ya que la articulación ya no queda donde debería.
La curvatura observada anteriormente es consecuencia directa de esa pérdida de anclaje. Otro efecto puede manifestarse más arriba en el dedo: al quedar la articulación distal fija en posición flexionada, el equilibrio entre las fuerzas de extensión y flexión en el resto del dedo se altera; por eso, en algunos casos se observa una hiperextensión de la articulación media.
Existen dos patrones principales. En uno, solo se rompe el tendón. En el otro, se desprende un fragmento óseo junto con el tendón; ambos patrones parecen similares externamente, pues el tendón va unido al fragmento. En la mayoría de los casos de dedo en martillo, sea cual sea el patrón, basta con usar una férula que mantenga recta únicamente la articulación distal. La cirugía se reserva para las fracturas más extensas, para las articulaciones desplazadas, o para aquellos dedos en los que el tratamiento previo no ha surtido efecto.
¿Qué podemos hacer al respecto?¶
El Dr. Kieran Hirpara, cirujano de extremidades superiores en el Mater Private Hospital Rockhampton, adapta el tratamiento a su lesión específica. Por lo general, los pacientes son derivados a nuestra clínica por su médico de cabecera; si un fisioterapeuta le ha recomendado consultarnos, igualmente necesitará una derivación de su médico de cabecera para poder acceder al reembolso de Medicare. En esa consulta, tomamos su historia clínica, examinamos el dedo y, si es necesario, ordenamos una radiografía para comprobar si se ha desprendido algún fragmento óseo y si la articulación sigue alineada.
En la mayoría de los casos de dedo en martillo, el primer paso es usar un yeso que mantenga recta únicamente la articulación distal. Por lo general le pedimos que lo lleve durante 6 a 8 semanas, tanto de día como de noche, y que evite el deporte o la actividad que provocó la lesión mientras lo lleva puesto. Un terapeuta de mano le colocará el yeso y le enseñará cómo usarlo sin irritar la piel; además, puede gestionar muchas de estas lesiones de principio a fin. Si el tendón se ha desgarrado entre 2 y 4 semanas antes de recibir tratamiento, el uso del yeso sigue siendo igual de eficaz que si se aplicara en las primeras 2 semanas; incluso un dedo al que se le colocó el yeso 12 semanas después de la lesión puede tratarse de forma similar a uno recién lesionado. Algunas personas necesitan llevar el yeso más de 12 semanas; el tiempo exacto depende en gran medida de su comodidad al usarlo. Un yeso nocturno adicional al diurno no aporta beneficios, por lo que no le pedimos que los use ambos. El tipo de yeso, ya sea hecho a medida o prefabricado, importa menos que el cumplimiento estricto de las indicaciones de uso.
Los analgésicos y antiinflamatorios no constituyen un tratamiento para el propio descenso del dedo; sin embargo, pueden aliviar el dolor durante los primeros días mientras el yeso hace su efecto.
La cirugía se considera cuando el yeso no ha funcionado, cuando el descenso del dedo le impide trabajar o cumplir ciertas tareas, o cuando la lesión implica un fragmento óseo de gran tamaño o la articulación se ha desplazado hacia la palma. La intervención consiste en reparar o volver a fijar el tendón responsable de la extensión del dedo, o en recolocar el fragmento óseo; posteriormente, el dedo se mantiene recto mediante un pequeño alambre y un yeso mientras cicatriza. Analizaremos juntos las opciones disponibles y decidiremos si la cirugía se adapta a su dedo y a sus objetivos.
Qué esperar¶
En la mayoría de los casos, el dedo en martillo mejora con tratamiento conservador en lugar de cirugía. El método habitual es usar una férula que mantenga recta únicamente la articulación distal; este método resulta eficaz para la mayoría de las lesiones, ya sea que solo se haya desgarrado el tendón o que se haya desprendido un pequeño fragmento óseo. Tanto el uso de férulas como la cirugía conducen a buenos resultados; por lo tanto, si el dedo se trata adecuadamente, se espera que quede recto y funcional.
El momento en que se inicia el tratamiento influye en la recuperación. Cuando se coloca la férula dentro de las dos semanas posteriores a la lesión, muy pocas personas presentan discapacidades duraderas. Si el tendón ha estado desgarrado entre 2 y 4 semanas antes de recibir tratamiento, la férula sigue siendo igual de eficaz; incluso un dedo al que se le coloca férula 12 semanas después de la lesión puede tratarse de forma similar a uno recién lesionado. Algunas personas necesitan mantener la férula puesta más de 12 semanas; el tiempo exacto depende en gran medida de su comodidad al usarla.
Si no se trata el dedo, la deformidad suele persistir. La articulación distal puede quedarse rígida en posición flexionada, y la articulación media puede presentar esa sobre-extensión ya mencionada. No obstante, algunas lesiones no tratadas evolucionan bien: los dedos con lesión tendinosa en martillo que permanecen sin tratamiento durante 2 a 4 semanas presentan bajas tasas de complicaciones a largo plazo, y los casos con fragmentos óseos grandes tratados de forma conservadora también tienen bajas tasas de complicaciones. Sin embargo, cuanto más se retrasa el tratamiento, menor es la previsibilidad del resultado; por eso el uso temprano de férulas es tan importante.
La cirugía se reserva para aquel grupo menor de pacientes en los que la férula no resulta suficiente, como en casos de fracturas más grandes o cuando la articulación se ha desplazado de su posición normal. Cabe señalar que la cirugía para estas fracturas conlleva una tasa de complicaciones del 41 %, en parte porque el tendón responsable de la extensión es delgado y tiene escasa irrigación sanguínea. No obstante, la cirugía realizada posteriormente en casos de fracturas óseas en martillo presenta muy pocas complicaciones. Su cirujano valorará todos estos aspectos con usted, sin imponerle un único camino terapéutico.
No existe una férula específica que se haya demostrado superior a otras, ya sea hecha a medida o prefabricada. Lo que realmente importa es usarla tal como se indica, y eso es algo que usted puede controlar.
Cuándo consultar a un especialista¶
Si la punta del dedo se dobla hacia abajo tras un golpe, conviene hacerse revisar en cuestión de días, no semanas. El inmovilizado temprano mediante férula brinda la mejor oportunidad de recuperar un dedo recto y funcional; por eso, en cuanto note esa deformidad, solicite a su médico de cabecera una derivación a un cirujano de mano. Lo mismo aplica si la articulación distal está hinchada, amoratada o sensible, y no se puede enderezar.
Algunos signos de alerta son más importantes que otros. Si se ha desprendido un fragmento óseo y afecta a la superficie articular, el dedo puede desviarse hacia la palma. Una fractura más grande o una que se detecta tarde incrementan ese riesgo. Consulte a un especialista si la punta del dedo queda visiblemente fuera de su posición normal, o si la articulación media comienza a doblarse hacia atrás mientras la punta permanece caída.
Acuda a urgencias si el dedo empieza a doler mucho más, se calienta, enrojece o se hincha rápidamente, o si tras una lesión fuerte no puede moverlo en absoluto.
En profundidad¶
Esta sección va más allá de lo necesario para que usted tome decisiones sobre su propio tratamiento. Vale la pena leer más sobre el dedo en maza, ya que las dos situaciones que habitualmente se consideran indicaciones claras para la cirugía —la presencia de un fragmento óseo grande y la persistencia de la flexión anormal del dedo tras el uso de férula— no están tan bien establecidas como se afirma con tanta certeza.
Ambos tratamientos producen buenos resultados, pero nadie sabe dónde está el límite¶
Una revisión sistemática sobre el tratamiento quirúrgico y no quirúrgico llegó a una conclusión excepcionalmente directa: ambos métodos generan buenos resultados clínicos, y no existen evidencias suficientes para determinar cuándo está indicada la intervención quirúrgica [1].
Esta segunda parte es la más importante. La controversia no radica en si alguno de los tratamientos funciona; el problema es que el umbral para optar por la cirugía —el punto en el que la fractura se considera demasiado extensa o la articulación demasiado subluxada— se basa en convenciones más que en evidencia comparativa.
Cuando un fragmento afecta a más de un tercio de la superficie articular, o cuando la falange distal presenta subluxación, generalmente se indica la cirugía; sin embargo, aún no se ha demostrado claramente ninguna ventaja significativa del tratamiento quirúrgico, incluso en esos casos complejos [2].
El uso de férulas funciona; lo importante es la duración¶
La evidencia científica sobre el uso de órtesis es más concreta. Dos de cada tres estudios hallaron un gran tamaño del efecto en la intervención con órtesis, que oscila entre 2,17 y 12,12, recomendándose una duración de inmovilización de 6 a 8 semanas, además de otras semanas adicionales si persiste el retraso [3].
Se destacan dos aspectos prácticos. El primero es que la férula debe mantener la punta del dedo recta de forma continua; la posición de la férula basta para mantener las extremidades del tendón juntas, pero unos pocos minutos de flexión durante el lavado reinician el proceso de curación. El segundo es que “las semanas adicionales si persiste el retraso” forman parte del protocolo de tratamiento, no son señal de fracaso terapéutico.
¿Por qué suele ser aceptable una ligera flexión residual?¶
Después del tratamiento, es frecuente que persista una pequeña limitación para la extensión; esto suele ser compatible con un uso normal de la mano. La articulación distal aporta relativamente poco a la fuerza de agarre, y la mayoría de las personas se adaptan a unos pocos grados de flexión sin notar ninguna alteración funcional.
Esto resulta relevante al valorar la conveniencia de una cirugía cuando el resultado no será perfecto: intervenir en esta articulación no está exento de riesgos; el fragmento óseo es pequeño, la piel es delgada, y la fijación mediante clavos o alambres en una articulación de este tamaño conlleva riesgos de infección, deformidad de las uñas y rigidez articular. Todo ello debe sopesarse frente a la ganancia estética y funcional, que suele ser mínima. Dado que los estudios mencionados no evidencian ventajas de la cirugía, ni siquiera en casos complejos, aceptar una ligera limitación funcional es una decisión acorde con la evidencia científica, en lugar de un simple compromiso.
La deformidad que no es dedo en martillo¶
El dedo en martillo forma parte de un grupo de lesiones del mecanismo extensor; se distinguen principalmente por el lugar del tendón donde se produce la ruptura: en la punta del dedo en el caso del dedo en martillo, en la articulación media en el caso de la deformidad en botón, y en la banda sagital en la articulación metacarpofalángica [4]. En las primeras fases, cuando la hinchazón dificulta la identificación del patrón clínico, estas lesiones suelen confundirse entre sí; además, cada una requiere una posición específica para la inmovilización mediante férula. Si se coloca una férula para dedo en martillo en una lesión en botón, se inmoviliza la articulación equivocada; por eso es fundamental confirmar el diagnóstico antes de proceder a seis semanas de inmovilización.
Referencias¶
[1] Lin JS, Samora JB. Manejo quirúrgico y no quirúrgico del dedo en martillo: una revisión sistemática. J Hand Surg Am. 2018;43(2):146-163.e2. https://doi.org/10.1016/j.jhsa.2017.10.004
[2] Lamaris GA, Matthew MK. Diagnóstico y manejo de las lesiones por dedo en martillo. Hand (N Y). 2016;12(3):223-8. https://doi.org/10.1177/1558944716642763
[3] Valdes K, Naughton N, Algar L. Tratamiento conservador del dedo en martillo: una revisión sistemática. J Hand Ther. 2015;28(3):237-46. https://doi.org/10.1016/j.jht.2015.03.001
[4] Lin JD, Strauch RJ. Lesiones cerradas del mecanismo extensor de partes blandas (dedo en martillo, dedo en botón y banda sagital). J Hand Surg Am. 2014;39(5):1005-11. https://doi.org/10.1016/j.jhsa.2013.11.018
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Overview¶
- Most mallet finger injuries can be managed non-surgically with splinting [5].
- Surgery is occasionally recommended for acute or chronic cases of mallet finger [5].
- Surgery is occasionally recommended for salvage of failed prior treatment in mallet finger cases [5].
- Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes [2].
- After a mallet-finger injury treated within two weeks by either internal or external splintage, few patients have significant persistent disability [7].
- Today most authorities splint only the distal joint for mallet finger deformities [9].
- There was insufficient evidence from comparisons tested within randomised controlled trials to establish the relative effectiveness of different custom-made or off-the-shelf finger splints used for treating mallet finger injury [10].
- The authors propose to treat all cases of mallet finger with a dorsal glued splint except for stage IV mallet finger [8].
- Stage IV mallet finger is treated with extra-articular pinning according to the proposed protocol in [8] [8].
- A simple splint is recommended as an alternative means of treating mallet finger [16].
- Delayed surgical management of bony mallet fingers demonstrated adequate functional outcome with minimal complications when compared with prior literature [1].
- Complication rates were low, suggesting that large-fragment mallet finger cases can be effectively managed conservatively [4].
- Absolute indications for surgical intervention for mallet fingers in the pediatric population remain unclear [3].
- The role of surgery for mallet fractures of the thumb remains unclear due to their uncommon nature and favorable radiographic findings [6].
- Surgery is generally indicated in the case of mallet fractures involving more than one-third of the articular surface [17].
- Surgery is generally indicated in all patients who develop volar subluxation of the distal phalanx [17].
- A significant advantage of surgical management even in complicated cases of mallet finger has yet to be clearly proven [17].
Anatomy & Pathophysiology¶
Mechanism of Injury¶
- Mallet finger most commonly involves a closed rupture of the terminal tendon with or without associated fracture of the distal phalanx [34].
- The usual mechanism of injury involves sudden passive flexion of the actively extended distal interphalangeal joint [21].
- Snagging the extending finger on a pants cuff, a bedsheet, or other object that suddenly flexes the extending DIP joint is a frequent cause of mallet finger [34].
- Less commonly, a forceful hyperextension injury of the DIP joint may result in a large fracture of the base of the distal phalanx involving one-third or more of the articular surface [34].
- Open mallet injuries are uncommon [34].
- The direction of force on the fingertip that results in a mallet fracture has yet to be determined [47].
- The precise mechanism of injury leading to different sizes of mallet fracture fragments might be difficult to delineate due to multiple variables, including tendon tension at the time of injury and the strain-rate-dependent mechanical properties of the affected bone and soft tissues [47].
Pathophysiology¶
- Mallet finger involves loss of continuity of the extensor tendon over the distal interphalangeal joint [14].
- Mallet finger reflects the loss of normal extensor force transmission via the terminal tendon insertion onto the distal phalanx [21].
- The unopposed flexor digitorum profundus pulls the distal joint into flexion [21].
- Mallet finger injuries may lead to an imbalance between flexion and extension forces more proximally in the digit [14].
- Disruption of the terminal tendon may be entirely confined to the tendon or may involve an avulsed fracture fragment from the dorsal lip of the distal phalanx proximal articular surface [21].
- Because the avulsed fragment includes the terminal tendon insertion, the clinical appearance of soft tissue and bony mallet fingers is similar [21].
- The distal joint rests in flexion, a posture that cannot be actively changed [21].
- Full passive extension of the distal interphalangeal joint is possible in mallet finger [21].
- Distal interphalangeal joint subluxation is expected with a mallet fracture fragment involving more than one-half of the joint surface [47].
- The distal interphalangeal joint has a remarkable ability to remodel [47].
Incidence and Demographics¶
- The most frequently involved digits are the small, ring, and middle fingers of the dominant hand, with a male predominance [34].
- Tendinous mallet fingers have been reported to occur from age 11 onward [34].
- In skeletally immature individuals, a transepiphyseal plate fracture may be seen [34].
- There may be a familial predisposition to mallet fingers [34].
- Elderly patients with osteoarthritis of the DIP joint may have “mallet” deformities that are not related to trauma [34].
- Individuals with hyperlax joints may have multiple pseudomallet swan neck postures that are unrelated to trauma [34].
Classification¶
- The Doyle classification system describes four types of mallet finger injuries [56].
- In the Doyle classification, Type IV represents mallet fractures and is further broken into three subtypes according to the size of articular involvement [56].
- The Wehbé and Schneider classification describes DIP joint subluxation and epiphyseal and physeal injuries [56].
- In the Wehbé and Schneider classification, articular injuries are subdivided into type A (less than one-third), type B (between one-third and two-thirds), and type C (larger than two-thirds of the joint) [56].
- The Doyle and Wehbé and Schneider classification schemes aid in standardizing injury patterns and guiding treatment algorithms [56].
- A 2023 review proposes a modification to the Doyle classification to make it more encompassing and less prone to interobserver error [26].
- The modified Mallet classification demonstrated strong to excellent agreement and interrater reliability across face-to-face, live tele-assessment, and video-based conditions [45].
- The modified Mallet classification is suggested to be appropriate for remote medical follow-up based on its reliability across assessment conditions [45].
- The interrater reliability of the Kellgren & Lawrence and OARSI classification systems for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed [44].
Clinical Presentation¶
- Mallet finger results in a flexion deformity of the distal finger joint [14].
- Mallet finger may lead to an imbalance between flexion and extension forces more proximally in the digit [14].
- Mallet injuries can be classified into four types based on skin integrity and the presence or absence of bony involvement [14].
- Mallet deformity accounts for a minority of sporting injuries [19].
- Mallet finger injuries are frequent in football [23].
- Mallet finger injuries are difficult to treat during the competitive season, often requiring delayed treatment or internal splinting [23].
- Early recognition of mallet finger injuries and referrals to a hand surgeon for treatment are crucial to avoid longterm disability [18].
- Approximately 50% of patients with a mallet fracture involving more than one-third of the articular surface of the distal phalanx do not progress to subluxation of the DIP joint [39].
- Fracture size and time to application of finger immobilizer are independent risk factors for the development of DIP joint subluxation in mallet fracture [39].
Investigations¶
- A radiograph should be obtained to determine whether a fracture is present [21].
- Radiographs should determine if the dorsal fragment is large and whether the distal phalanx is subluxed palmarward [21].
Treatment¶
Non-Operative Management¶
- Splinting of the distal interphalangeal joint for 6 to 8 weeks has yielded good results while minimizing morbidity in the majority of patients [14].
- Non-operative management of mallet fractures, regardless of fracture classification, joint congruence or pre-existing degenerate change in the DIP joint, is safe and yields predictably good outcomes in most patients [15].
- Conservative management of tendinous mallet finger injuries that have been neglected for 2 to 4 weeks can be treated as well as those injuries in patients presenting within the first 2 weeks of injury with low long-term complication rates [12].
- A mallet finger caused by avulsion of the extensor tendon from the distal phalanx can be satisfactorily treated by splinting 12 weeks after injury, as described for an acute injury [13].
- Prolonged splinting and splinting longer than 12 weeks may be successful, with the duration limited by the patient’s tolerance of the splinting [13].
- Supplemental night splinting does not improve the outcome of mallet finger in terms of extensor lag, disability, or satisfaction with treatment [24].
- There was insufficient evidence from comparisons tested within randomised controlled trials to establish the relative effectiveness of different, either custom-made or off-the-shelf, finger splints used for treating mallet finger injury [10].
- Excellent functional outcome can be achieved with splintage and avoidance of the causative sport while splinted [19].
- A hand therapist can treat type 1 mallet finger injuries as effectively as a surgeon [27].
- A hand therapist can treat mallet finger injuries of type 1 as effectively as a surgeon, with a method of immobilisation that offers practically no complications regarding skin condition [40].
- Large-fragment mallet finger cases can be effectively managed conservatively with low complication rates [4].
- The clinical efficacy of elastic taping for the treatment of mallet finger injuries remains to be tested vigorously [37].
- Conventional treatment protocols usually recommend 6 weeks of immobilization in a neutral or slightly flexed splint, followed by staged mobilization [33].
- Giddins (2022) suggested that only 3-4 weeks of immobilization for bony mallet injuries is sufficient, reflecting faster bone healing [33].
- A retrospective study examined outcomes of acute bony mallet injuries treated with 4 weeks of static immobilization in a splint, followed by graduated mobilization [33].
Operative Management¶
- Surgery is occasionally recommended for acute or chronic cases or for salvage of failed prior treatment [5].
- Surgical management may be considered for acute and chronic mallet lesions in patients who have failed nonsurgical treatment, are unable to work, or have specific functional needs [14].
- Surgery is generally indicated in the case of mallet fractures involving more than one-third of the articular surface as well as in all patients who develop volar subluxation of the distal phalanx [17].
- A significant advantage of surgical management even in complicated cases (fractures >1/3 articular surface or volar subluxation) has yet to be clearly proven [17].
- If the distal phalanx droops severely but passive extension in the distal interphalangeal joint is still satisfactory, surgery may be indicated depending on the patient’s needs [13].
- Scar overlapping suture for treating chronic tendinous mallet finger in children is safe and effective [41].
- A deepithelialised pedicled skin flap technique seems to be a new reliable alternative in the treatment of chronic mallet finger [46].
Surgical Techniques and Postoperative Care¶
- For secondary repair of chronic mallet finger, a small V-shaped or U-shaped incision is made convex distally, with the tip no closer than 5 mm proximal to the nail base on the dorsum of the finger [13].
- The surgical flap is developed in the plane between the tendon and the subcutaneous fat and elevated proximally to expose the extensor tendon with its intervening scar [13].
- The junction of the normal tendon with the scar is identified, and the tendon is severed transversely proximal to the joint, leaving the insertion of the tendon into bone [13].
- Sufficient scar or tendon is resected to allow closure of the gap with the finger in maximal extension [13].
- The joint is immobilized with a transarticular 0.045-inch Kirschner wire to support and protect the repair [13].
- The extensor tendon is repaired with 4-0 monofilament nylon or 4-0 monofilament wire as a pull-out roll stitch, with no additional sutures required [13].
- The skin is closed with interrupted 5-0 nylon or 4-0 nylon as a dermotondermal suture [13].
- The finger is maintained in extension with a compressive dressing and supported with a volar splint for post-operative comfort and to avoid reinjury [13].
- Sutures are removed at 10 to 14 days, and the distal joint is maintained in extension with the Kirschner wire protected by a small metal splint for 4 weeks [13].
- The Kirschner wire is removed after 4 to 6 weeks, and the repair is protected with a splint for 8 weeks [13].
- Normal activities are progressively resumed after the splinting period [13].
Complications¶
- The complication rate after operative treatment of mallet fracture was 41% [51].
- The high complication rate after operative treatment of mallet fracture is likely attributable to anatomical factors such as thin extensor tendon and poor blood supply [51].
- Delayed surgical management of bony mallet fingers demonstrated minimal complications [1].
- Conservative management of tendinous mallet finger injuries neglected for 2 to 4 weeks has low long-term complication rates [12].
- A surgical technique for acute combined tendon and bone mallet fingers reported no complications such as infection, nonunion, or nail deformity in the series [29].
- Complication rates were low in large-fragment mallet finger cases managed conservatively [4].
Recovery¶
- Most mallet finger injuries can be managed non-surgically with splinting, although surgery is occasionally recommended for acute or chronic cases or for salvage of failed prior treatment [5].
- The authors propose to treat all cases of mallet finger with a dorsal glued splint except for stage IV mallet finger, which they treat with extra-articular pinning [8].
- Most authorities splint only the distal joint for mallet finger deformities [9].
- Mallet finger injuries are frequent in football and difficult to treat during the competitive season, often requiring delayed treatment or internal splinting [23].
Key Evidence¶
- [L4] Delayed surgical management of bony mallet fingers demonstrated adequate functional outcome with minimal complications when compared with prior literature. [1] (10.1177/1558944719840749)
- [L4] Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes. [2] (10.1016/j.jhsa.2017.10.004)
- [L4] Absolute indications for surgical intervention for mallet fingers in this population remain unclear. [3] (10.1016/j.jhsa.2018.03.037)
- [L4] Complication rates were low, suggesting that large-fragment mallet finger cases can be effectively managed conservatively. [4] (10.1186/s12891-026-09787-w)
- [L5] Most mallet finger injuries can be managed non-surgically with splinting, although surgery is occasionally recommended for acute or chronic cases or for salvage of failed prior treatment. [5] (10.1007/s11552-014-9609-y)
- [L3] The role of surgery for mallet fractures of the thumb remains unclear due to their uncommon nature and favorable radiographic findings. [6] (10.1177/1558944716672192)
- [L1] After a mallet-finger injury treated within two weeks by either method few patients have significant persistent disability. [7] (10.1016/s0072-968x(82)80011-9)
- [L5] The authors propose to treat all cases of mallet finger with a dorsal glued splint except for stage IV mallet finger, which they treat with extra-articular pinning. [8] (10.5999/aps.2016.43.2.134)
- [L5] Today most authorities splint only the distal joint for mallet finger deformities. [9] (10.1016/s0749-0712(21)00059-7)
- [L1] There was insufficient evidence from comparisons tested within randomised controlled trials to establish the relative effectiveness of different, either custom-made or off-the-shelf, finger splints used for treating mallet finger injury. [10] (10.1002/14651858.cd004574.pub2)
- [L3] Conservative management of tendinous mallet finger injuries that have been neglected for 2 to 4 weeks can be treated as well as those injuries in patients presenting within the first 2 weeks of injury with low long-term complication rates. [12] (10.1016/j.jhsa.2014.06.140)
- [L5] [14] (10.5435/00124635-200509000-00007)
- [L3] Non-operative management of mallet fractures, regardless of fracture classification, joint congruence or pre-existing degenerate change in the DIP joint, is safe and yields predictably good outcomes in most patients. [15] (10.1177/1753193421992986)
- [L2] The study recommends this splint as an alternative means of treating mallet finger. [16] (10.1136/emj.10.3.244)
- [L4] Although surgery is generally indicated in the case of mallet fractures involving more than one-third of the articular surface as well as in all patients who develop volar subluxation of the distal phalanx, a significant advantage of surgical management even in those complicated cases has yet to be clearly proven. [17] (10.1177/1558944716642763)
- [L4] Early recognition of these injuries and referrals to a hand surgeon for treatment are crucial to avoid longterm disability. [18] (10.1016/j.hcl.2012.05.042)
- [L4] Mallet deformity accounts for a minority of sporting injuries, but excellent functional outcome can be achieved with splintage and avoidance of the causative sport while splinted. [19] (10.1054/jhsb.2000.0484)
- [L5] Mallet finger injuries are frequent in football and difficult to treat during the competitive season, often requiring delayed treatment or internal splinting. [23] (10.1016/j.hcl.2012.05.043)
- [L1] Supplemental night splinting does not improve the outcome of mallet finger in terms of extensor lag, disability, or satisfaction with treatment. [24] (10.1007/s11552-013-9600-z)
- [L4] [26] (10.1016/j.jhsa.2022.10.013)
- [L4] A hand therapist can treat type 1 mallet finger injuries as effectively as a surgeon. [27] (10.1197/j.jht.2008.04.002)
- [L4] The study describes a surgical technique for acute combined tendon and bone mallet fingers and reports good to excellent long-term results with no reported complications such as infection, nonunion, or nail deformity in the series. [29] (10.1016/j.jhsa.2014.11.011)
- [L4] [33] (10.1177/17531934251382017)
- [L4] Most fingers ended with a dorsal prominence, but this did not significantly affect function. [34] (10.2106/00004623-198466050-00003)
- [L4] The clinical efficacy of the proposed method of elastic taping for the treatment of mallet finger injuries remains to be tested vigorously. [37] (10.1016/j.jht.2014.02.005)
- [L2] Approximately 50% of patients with a mallet fracture involving more than one-third of the articular surface of the distal phalanx do not progress to subluxation of the DIP joint; fracture size and time to application of finger immobilizer are independent risk factors for the development of DIP joint subluxation in mallet fracture. [39] (10.1177/1753193414554556)
- [L4] A hand therapist can treat mallet finger injuries of type 1 as effectively as a surgeon, with a method of immobilisation that offers practically no complications regarding skin condition. [40] (10.1177/175899830501000103)
- [L4] Scar overlapping suture for treating chronic tendinous mallet finger in children is safe and effective. [41] (10.1186/s13018-019-1106-0)
- [L4] The interrater reliability of the Kellgren & Lawrence and OARSI classification systems for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed. [44] (10.1016/j.jhsa.2024.03.012)
- [L3] The modified Mallet classification demonstrated strong to excellent agreement and interrater reliability across face-to-face, live tele-assessment, and video-based conditions, suggesting it is appropriate for remote medical follow-up. [45] (10.1177/17531934231196118)
- [Paper] This method seems to be a new reliable alternative in the treatment of chronic mallet finger. [46] (10.1016/j.injury.2013.01.013)
- [L5] [47] (10.1016/j.jhsa.2008.04.014)
- [L4] The complication rate after operative treatment of mallet fracture was 41%, likely attributable to anatomical factors such as thin extensor tendon and poor blood supply. [51] (10.1054/jhsb.2000.0440)
- [L5] [56] (10.1177/1753193414554772)
References¶
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