Best treatment for mallet finger.
Date First Published:
April 23, 2010
Last Updated:
May 6, 2010
Report by:
Shafic Said Al-Nammari, SpR, Trauma & Orthopaedics, Royal London Rotation (Barnet Hospital)
Search checked by:
Nawfal Al-Hadithy, Barnet Hospital
Three-Part Question:
In [an adult patient presenting with an acute mallet finger suitable for non-operative treatment] what is [the best method of treatment] to [facilitate an optimum outcome]?
Clinical Scenario:
A middle aged man presents with a painful right index finger after stubbing it on a door. He clinically has a classic mallet deformity with swelling and tenderness over the dorsum of the distal interphalangeal joint and loss of active extension. Radiographs confirm there is no fracture. You wonder how this can be best managed non-operatively.
Search Strategy:
OVID interface on the world wide web. 1966 – April 2010
Search Details:
[({mallet finger OR drop finger OR baseball finger.mp} AND {extensor tendon AND zone one.mp} AND {extensor tendon AND distal interphalangeal joint}]
LIMIT to English
LIMIT to English
Outcome:
577 papers found of which 573 were either irrelevant or of insufficient quality for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. Pike J, Mulpuri K, Metzger M, Ng G, Wells N, Goetz T. Apr-10 Canada | 87 patients with 87 mallet fingers. Adult patients only, acute injuries only, bony (small fragment ie Doyle Type 1) and soft tissue types, no thumbs. Randomised to one of 3 splint types: volar padded aluminum splint, dorsal padded aluminum splint or custom made thermoplastic splint. Splints were continued for 6 weeks full-time. | PRCT | Clinical Extensor Lag | No significant difference found ( p 0.5). Dorsal splint: 6 degrees. Volar splint: 5 degrees. Custom thermoplastic splint: 7 degrees. | 9 cases crossed over treatment groups due to poor compliance or complications. Short follow-up of only 24 weeks for clinical review and 12 weeks for radiographic review. |
| Radiographic lag | No significant difference found (p 0.12). Dorsal splint: 16.2 degrees. Volar splint: 13.6 degrees. Custom thermoplastic splint: 9 degrees. | ||||
| Michigan Hand Outcome Questionnaire Score | No significant difference found (p 0.78). Dorsal splint: 80. Volar splint: 80. Custom thermoplastic splint: 79. | ||||
| Complications | No significant difference found (p 0.95). Dorsal splint: 2 minor, 1 major. Volar splint: 2 minor. Custom thermoplastic splint: 2 minor. | ||||
| The conservative treatment of mallet finger Maitra A, Dorani B. 1993 UK | 60 patients with 60 mallet fingers. Adult & paediatric patients, acute injuries only, bony (small fragment) and soft tissue types, no thumbs. Randomised to custom made padded aluminium alloy malleable finger splint (trial splint) or stack splint (control splint). Splints were continued for 6 weeks full-time. | PRCT | Outcome according to Abouna and Brown criteria (1968): Success= extension loss: 0-5°, no stiffness, normal active flexion and extension. Improved = extension loss: 6-150, no stiffness, normal flexion. Failure= extension loss >150 stiffness or impaired flexion. | No significant difference found. Success 37% trial splint vs. 33% stack splint, Improved 20% trial splint vs. 20% stack splint, failure 43% trial splint vs. 47% stack splint. | Randomisation method not stated. Assessors not blinded. Short follow-up time of only 9 weeks. Vague description of time off work and joint stiffness. |
| Time off work | No significant difference found. 25% in each group off for 6 weeks. | ||||
| DIP and PIP joint stiffness | No significant difference found. | ||||
| Complications | Significant difference found (p<0.01). 6.6% trial splint vs. 33% stack splint. | ||||
| Mallet finger: a trial of two splints. Warren RA, Norris SH, Ferguson DG. 1988 UK | 114 patients with 116 mallet fingers. Adult & paediatric patients, acute injuries only, bony (small fragment) and soft tissue types, no thumbs. Randomised to abouna splint (trial splint) or stack splint (control splint). Splints were continued for 6 weeks full-time. | PRCT | Outcome according to Abouna and Brown | No significant difference found. Success: 39% abouna splint vs. 33% stack cplint, improved 14% abouna splint vs. 19% stack splint, failure 47% abouna splint vs. 48% stack splint. | Quasi randomised based on odd and even hospital numbers. Assessors not blinded. 7% lost to follow-up. Variable follow-up. |
| Patients generally satisfied with the splint | Significant difference found. 57% abouna splint vs. 83% stack splint. | ||||
| A comparative controlled trial of a new perforated splint and a traditional splint in the treatment of mallet finger. Kinninmonth AW, Holburn F. 1986 UK | 54 patients with 57 mallet fingers. Age range not known, acute and chronic injuries, bony (size not stated) and soft tissue types, no thumbs. Randomised to custom made perforated splint (trial splint) or stack splint (control splint). Splints were continued for 6 weeks full-time. | PRCT | Lag outcome in patients able to tolerate initial splint: excellent <5 degrees, good <10 degrees | Significance not stated. Excellent/good result in 92% perforated splints vs. 86% stack splint. | Randomisation method not stated. Assessors not blinded. Age range not clear. Mixed acute and chronic. |
| Lag outcome including patients who had to change initial treatment | Significance not stated. Excellent/good result in 89% perforated splints vs. 69% stack splint. | ||||
| Treatment failure, defined as need to change splint type and/or excessive lag deformity | Significant difference found. 7% perforated splint vs. 33% stack splint. |
Author Commentary:
There are four PRCT's of varying quality and power in this area. The ideal splint remains controversial. The most recent and best designed study by Pike et al showed no significant difference in outcome between the three different types of splint used. Maitra et al suggest no significant difference in lag outcome between splints but with a significant increase in soft tissue complications in the stack splint group. Warren et al showed no significant difference in lag outcome between splints but with patients being more satisfied with their treatment in the stack splint. Kinnonmonth et al found no significant difference in lag outcome but with a significantly increased number of patients not able to tolerate the stack splint. It is worth noting that the trial splints being examined by Maitra and Kinnonmonth were both custom made.
Bottom Line:
There is currently no gold standard non-operative management. Patients can be adequately managed with a standard stack splint. Where local expertise permits custom made paddded aluminium alloy malleable splints or custom made perforated splints may have advantages in terms of reduced soft tissue complications and increased patient compliance.
References:
- 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.
- Maitra A, Dorani B.. The conservative treatment of mallet finger
- Warren RA, Norris SH, Ferguson DG.. Mallet finger: a trial of two splints.
- Kinninmonth AW, Holburn F.. A comparative controlled trial of a new perforated splint and a traditional splint in the treatment of mallet finger.