Mallet finger

What is Mallet finger?

 Mallet finger is an injury to the tendon of the finger that straightens its end joint. It is also called baseball finger. This injury can be caused by a strike with a ball at the tip of the finger or thumb. The injury usually damages the tendon and in some cases a part of bone gets pulled out along with the tendon. This will lead to the end finger joint to bend towards the palm and you could not straighten the finger.

Mallet finger commonly affects ring, long and small finger of the dominant hand.  It occurs in young and middle age males especially in athletes and sports person and in some old females. 74% of the cases of mallet finger affect the dominant hand. 90 % of injuries happen to long, ring and small finger of the hand.

 

What are the symptoms of Mallet finger?

Mallet finger causes pain, swelling and bruising in the backside of fingertip. Marked Deformity is seen. The end of the finger remains in bent position.  You will able to straighten the finger using other hand, however you will not be able to hold the finger straight on its own. In rare cases, blood accumulates under the nails of affected finger and nails may get detached from its nail bed.

 

How is it diagnosed?

It is diagnosed by your medical history, history of injury, physical examination and an X-ray.  X-ray helps to determine whether there is an associated fracture. CT scan is performed in selected patients to assess the magnitude of injury and plan for surgery.

 

What happens if nothing is done?

If it is left untreated, it may cause stiff, deformed finger that could lead to a swan neck deformity.

 

How is it treated?

Majority of the mallet injuries could be treated conservatively by closed reduction, immobilization by splint, application of ice packs, painkillers and hand therapy.

Surgery is indicated in

  • Chronic injury
  • Open injury
  • Volar joint subluxation of distal phalanx
  • Persistent pain
  • Large fractures
  • >50% of articular surface
  • Mal- alignment of the finger
  • Arthritis
  • Unstable fracture
  • Nail bed laceration
  • Late presentation with swan neck deformity

 

What are the non-operative treatments?

The non-operative treatment involves the following-

  • Closed reduction- your surgeon will realign your tendon/bones by making your finger straight.
  • Immobilization- after closed reduction, your surgeon will give you a splint to wear for 6 to 8 weeks to keep the tip of other finger straight and bones/tendons aligned during the healing process. You have to wear for 24 hours a day for 6 weeks and you have to wear it only at night for further 2 weeks. You have to avoid any activities that require the use of the finger to prevent stress and new injury to the finger.
  • Ice packs (frozen peas bag)– you can also apply ice on the joint for 20 -30 minutes in every 2 to 3 hours in first few days of the injury as it can relieve pain and swelling.
  • Medications– anti-inflammatory medicines like ibuprofen or aspirin may be given to regulate pain and swelling for few days, as long-term consumption of these medicines can delay fracture healing and may cause damage to your kidneys and stomach.
  • You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your other fingers, wrist, elbow and shoulder to maintain the flexibility and prevent stiffness of its joints.
  • Hand therapy- The therapists apply custom made splint to keep your joint a bit hyperextended to help with the healing. Your hand is prone for getting stiff and hand therapy under the supervision of your surgeon is paramount for optimal outcome after these injuries

 

What does the operation involve?

Surgery in selected cases is aimed at repair of the tendon and to restore the joint surface.

  • You are admitted to the hospital and the operation is usually performed as a day case.
  • The operation is performed under general anaesthesia or local anaesthesia (Block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation, but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
  • A tourniquet is tied around the base of finger to reduce blood loss during surgery.
  • Procedure– once anaesthesia is given to the patient, antibiotics are also given to him to prevent any infection during and after the operation. A cut or incision is made in the affected site and the bone fragments with tendon are repositioned to their normal position. This procedure is called open reduction. Then, the bone fragments are fixed with the help of plates, pins or screws so that they remain in the proper position while healing process. This process is called internal fixation. In some cases, the fracture is reduced and held only with pins. The skin is closed with the help of absorbable sutures.
  • The operation takes around an hour and most patients are discharged on the same day.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Your finger is rested in a splint for 2 weeks to protect it from injury and allow proper healing.
  • You should keep your arm elevated (above the level of your heart) most of the times as it prevents swelling. Besides keep moving your fingers, elbow and shoulder.
  • Before discharge, your physiotherapist will teach you gentle exercises of the hand, wrist, elbow and shoulder that you can start soon after the operation from the first day.
  • The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
    • Following ORIF with plates and screw, usually the plaster is changed to splint and hand therapy commenced
    • If the fracture is fixed with pins, that has to stay for 4-6 weeks and removed in the clinic after check x-rays
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • You will be guided by your surgeon and hand therapists based on radiographic (X-ray) and clinical union of the fracture. In majority of the cases, you could start a gentle range of movement (ROM) exercises around 4 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around 8 weeks. It is advisable to avoid contact sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.

 

Are there any risks?

  • Infection
  • Stiffness in the finger
  • Extensor lag
  • Swan neck deformity
  • Post-traumatic arthritis
  • Hardware complications- screw penetration into the joint, tendon irritation
  • Injury to digital nerve and blood vessels
  • Tendon injury
  • Fixation failure
  • Malunion
  • Non-union
  • Complex regional pain syndrome

 

What are the results of the operation?

Most patients regain full function and strength of the injured hand with fewer major complications (<1%). It is more predictable under the experiences of the author.

 

When can I return to driving and work?

You can get back to work in few days if you have a desk job, however might take 2- 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3 months and you should be able to resume driving in 2-4 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.

  Mallet finger_1

Soft tissue mallet injury – Tendon snapped from its attachment to tip of the finger

Mallet finger_2

Bony mallet injury – tendon avulsed with a fragment of bone

 

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