What is a Mallet Finger?
Mallet finger is a term used to describe a rupture of the finger "terminal tendon." This terminal tendon is the tendon that inserts just below your fingernail and is responsible for extension of your fingertip. In addition to the terminal tendon rupturing, some patients may also break off the piece of bone the terminal tendon attaches to. This condition is termed a "bony mallet finger". The term mallet finger is derived because once this happens, the fingertip will usually droop to a varying degree, and if it droops enough, it resembles the look of a mallet!
Why Does It Occur?
Mallet finger usually occurs secondary to an impact/trauma to the tip of the finger. This most commonly occurs because of a direct fall onto a straight finger, or during sports like volleyball, football, basketball, and baseball. This impact/trauma places significant stress on the terminal tendon, ultimately causing it to rupture and sometimes break off the piece of bone it attaches to.
Patients with mallet finger are unable to extend their fingertip. The fingertip will droop and be resting in a flexed (i.e. towards the palm of the hand) position. Often the finger can be passively extended with the help of another finger, but will not stay up when let go. With a standard mallet finger, the pain may be surprisingly minimal. Pain and swelling are more likely with a bony mallet finger.
Typically, Dr. Steven Lee will order an x-ray to rule out a fracture or other pathology.
The most important factor when considering non-operative versus surgical management is whether or not there is a bony mallet present. Surgery is usually necessary for a bony mallet that is significantly displaced (i.e. separation of fracture fragments), or when the joint has subluxated (partially dislocated).
Non-operative treatment consists of splinting the finger in extension 24/7 for approximately 6-8 weeks. 24/7 can not be stressed enough. The clock with respect to time in the splint starts over should the patient flex the fingertip at all (even for a second!) during the 6-8 week period of splinting. Occupational therapy (OT) is usually started gradually while weaning down splinting in order to regain the strength and mobility lost during the splinting period.
Splinting the finger in extension brings the terminal tendon back to its normal bony attachment below the fingernail. This allows the tendon to heal, which usually takes 6-8 weeks.
Even though the actual treatment concept is so simple (just have to wear the splint!), you would be surprised how many patients (as much as 30% or more!) either purposefully or accidentally take off the splint. If the non-operative treatment fails, the surgical treatment for this often leads to suboptimal results, so it's very important to follow through with the directions of wearing the splint!
Dr. Steven Lee may recommend surgery under certain conditions: if the patient failed non-operative treatment, or if it was a bony mallet with either joint subluxation or a severely displaced fracture. Dr. Lee may also offer surgery for regular mallet fingers as an alternative to splinting. Part of this reason is that patients are often not tolerant of a splint being worn 24/7 or they want to maximize the percentage chance that they may have a better finger. We are often asked what we would do if it were our own finger. Many hand surgeons, including Dr. Lee, would opt to have the surgery for pin fixation as it would allow him to take the splint off, wash and sterilize his hand, and allow him to continue his duties as a surgeon, including operating.
The surgical treatment for a standard mallet finger consists of placing a single pin across the joint. The actual act of doing this typically takes less than 5 minutes to do (although the total length of time you would be in the operating room is much longer).
For a displaced or subluxated bony mallet finger, a Closed Reduction Percutaneous Pinning (CRPP) is performed. During this procedure, small wires are placed through the skin and into bone. Often up to three wires can be utilized. One wire is placed to hold the fingertip in extension while the other wires are placed through the displaced bony fragment. The wires placed through the bony fragment bring the fragment back to its normal position and hold it in that position to allow for healing.
It's important to note that a successful result after the non-operative or operative treatment of mallet fingers often leads to a finger that may still look a little bit bent. Part of this reason is that as part of the healing process, your body often puts down a fair amount of scar tissue on the top of the finger which may make the finger look bent when it really is not. Part of this reason may also be because as the tendon heals, it can heal in a slightly stretched out position. If the mallet finger does not heal properly, the finger may result in a Swan neck deformity.
Patients are required to wear a finger extension splint after surgery. Unlike non-operative treatment, since the joint is also held in extension by one of the k-wires, patients may remove their splint to wash the finger. K-wires are usually removed somewhere between 4-6 weeks. At this point in time, night splinting is usually continued for an additional 2-4 weeks. The patient will then normally start therapy at the 6-8 week mark in an effort to restore strength and mobility to the finger.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.