Arch Hand Microsurg.  2023 Sep;28(3):137-149. 10.12790/ahm.23.0016.

Current concepts in traumatic mallet finger management

• Lee JK
• Kang S
• Park JW

• KMID: 2545524
• DOI: http://doi.org/10.12790/ahm.23.0016

Abstract

Mallet finger deformities can be divided into tendinous deformities caused by tendon rupture and bony deformities caused by fracture. In many cases, conservative treatment is possible. The goal of treating traumatic mallet finger deformities is to accurately restore the ruptured tendon or fractured bone to its proper position, correct extension lag or flexion contracture, prevent joint arthritis, and restore the full range of motion through appropriate range of motion exercises at the right time. In cases of tendinous mallet finger, immobilization with a splint or cast for at least 6 weeks in the extended position is required. During this period, flexion at the distal interphalangeal joint should be strictly limited, while movement at the proximal interphalangeal joint is allowed. Patient compliance with the protocol is essential for achieving good treatment outcomes. If conservative treatment fails or if the deformity recurs after initial surgery, satisfactory results can be achieved through tenodermodesis surgery. If the bony mallet finger involves a bone fragment of 3 mm or more or subluxation of the distal phalanx, surgical treatment is recommended. The primary surgical treatment involves closed reduction and percutaneous pinning with the extension block technique.

Keyword

Mallet finger; Tendinous mallet finger; Bony mallet finger; Extension block pinning; Tenodermodesis

Figure

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  Fig. 1. Doyle’s classification of mallet finger. (A) Type 1, (B) type 2, (C) type 3, (D) type 4A, (E) type 4B, and (F) type 4C.

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  Fig. 2. Anatomy of finger extensors (A, posteroanterior and B, lateral).

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  Fig. 3. Failed case of primary repair for tendinous mallet finger. (A) A 70-year-old woman underwent open tendon repair for tendinous mallet finger at another hospital; however, she was referred for a worsening deformity (40°) compared to the initial presentation. (B) We performed tenodermodesis under local anesthesia, and the deformity improved by 10° within 2 months postoperatively.

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  Fig. 4. The authors’ method for modified tenodermodesis. (A) A transverse incision is made on the skin, partially separating the tendon and skin into proximal and distal parts. (B) The elongated terminal tendon with scar tissue is then incised horizontally. A Kirschner wire (K-wire) is obliquely inserted into the joint to fix it with the distal interphalangeal joint fully extended. (C) The extensor tendon is sutured using a 4-0 nylon suture. Both ends of the suture are fixed to the skin and removed 4 weeks after the surgery. (D) After the tendon is sutured, redundant skin is removed. The two remaining skin ends are sutured using vertical mattress suture and removed 2 weeks postoperatively. The K-wire is removed 6 weeks after the surgery, and joint motion is initiated. A brace that can keep the distal interphalangeal joint in an extended state is worn while sleeping for 2 weeks after the removal of the K-wires. At 8 weeks postoperatively, joint motion is fully allowed without any immobilization.

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  Fig. 5. Swan neck deformity from tendinous mallet finger. (A, B) A 25-year-old man visited the outpatient clinic with a gross deformity of his fifth finger after a twisting injury in the distal interphalangeal (DIP) joint. The DIP joint exhibited a 60° extension lag with 30° of proximal interphalangeal (PIP) joint hyperextension, indicative of swan neck deformity. (C) The patient also had gross PIP hyperextension in the other digits, indicating physiological PIP joint laxity.

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  Fig. 6. Modified extension block pinning technique. (A) One or two extension blocking pins are inserted from the dorsal aspect of the proximal phalanx head at around a 45° angle to prevent dorsal fragment displacement. (B) Although the distal phalanx segment is extended, the reduction is not perfect. (C, D) With the aid of a dorsal counterforce reduction Kirschner wire (K-wire), an axial transarticular K-wire is inserted from the volar aspect of the distal phalanx. (E) A dorsal counterforce K-wire is additionally inserted to fix the dorsal fragment in addition to the conventional extension block technique.

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  Fig. 7. Osteophyte excision and tenodermodesis. (A) A 32-year-old man who had been injured 4 years ago presented with a painful dorsal bump and a 45° extension lag (arrow) in the distal interphalangeal joint (DIPJ). (B) After making a Z-shaped skin incision, the subsequent extensor tendon was exposed over the DIPJ. (C) The extensor tendon, including the joint capsule, was incised. (D) The dorsal osteophyte was trimmed with osteotomy. (E) After inserting a transaxial Kirschner wire (K-wire) in a fully extended DIPJ, the overlapping extensor tendon was excised, and both ends were repaired with running sutures. (F, G) The redundant skin was excised, followed by interrupted skin sutures. (H) The range of motion and lateral x-ray were measured in the postoperative 3 months.

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  Fig. 8. Arthrodesis after traumatic osteoarthritis. (A, B) A 53-year-old man, who was a heavy smoker, was treated with a modified extension block pinning technique for a bony mallet finger injury of the right third finger. (C) The fracture union was delayed after the removal of the pins and, despite the fracture union, the patient’s distal interphalangeal joint developed arthritic changes. Due to the persistent pain during daily activities, the patient underwent arthrodesis with 2.2-mm headless screw fixation. (D–F) The arthrodesis was successful, and the functional outcome was acceptable at the final outpatient follow-up visit.

Reference

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