Mallet Finger

“He’s old enough to know what’s right but young enough not to chose it”

from the song “New World Man” by Rush

There are a number of seemingly minor hand injuries that can cause a lot of trouble, and the injury know as “mallet finger” is one of those.  This injury usually occurs during some very minor and normal activity, and people often then feel a tear or pop and realize they can’t straighten the end of their finger.  I’ve seen patients who did something as trivial as flicking an object and cause a mallet finger.

The injury occurs when the tendon that straightens the end of the finger either stretches or pulls away from the bone.  Since this is the only thing that can straighten the end of the finger the joint gets bent down and can’t be straightened.  The patient can push the finger up straight but it won’t stay there.  Many people intuitively know to try and splint their finger straight, but the problem is that this injury takes a long, long time to heal and requires a lot of patience by both the patient and the physician.

The tendon usually pulls off the bone, but every once in a while the tendon will pull off with a piece of bone.  The bone piece can be a small fleck or it can be very large, sometimes up to half the joint surface of the end of the joint.  The good news is that almost all of these injuries can be treated without surgery.  The bad news is that treatment often requires wearing a splint for a minimum of six weeks and often times the splint has to be worn even longer.

The key to treatment is to keep the finger completely straight during the time of treatment.  This means keeping the splint on all the time, 24/7 during the treatment.  This requires a lot of discipline because it’s easy to bend the finger when you wash or clean your hand.  However, if your finger bends during the treatment it will stretch out the tissue that is healing the tendon and the tendon will continue to drop down.  If a patient can’t, or won’t keep the splint on, then you can consider other options.  One is to go to surgery and place a pin across the joint.  This will hold the joint straight as long as the pin is in, and isn’t a bad option for people who can’t wear splints due to their work or their personal preference.  Pins work well, but they are not without their problems.  The pins can get infected, and if the patient isn’t careful and is very overactive the pin can break.  I offer pinning to patients that I think need them, but I always caution them about the possible complications.

Another problem with mallet fingers is that the patient can be very disciplined and faithful in their treatment and still have problems getting the tendon to heal.  I really don’t have a good explanation for this other than the fact that all of us heal differently and in some cases the tendon just won’t go back like it should.  Patients often ask me if I could repair the tendon, and the interesting thing is that the tendon actually stretches out rather than tearing.  So suturing or repairing the tendon usually causes a lot of scarring and stiffness so I usually don’t recommend this. Even under the best of circumstances it’s hard to get a perfect outcome.  Usually the finger will lack just a little bit from straightening up all the way, but usually after treatment the finger is much straighter than before and works pretty well.

Most mallet fingers that have a fracture can also be treated without surgery.  However sometimes a very large piece will pull off and surgery will be necessary to reattach the bone fragment and keep the joint in place.

If a patient has a mallet finger that’s occurred in the past, you can still try a splint up to 2 or 3 months after the original injury.  There are some surgeries that can be done on an old mallet finger to rebalance the finger and get the tendon to straighten, but they are very hard to pull off and get a good result.  The bottom line is that it’s best to be treated as soon as possible after the injury.  Most patients will have a good outcome, although not perfect, outcome from their mallet finger, but the treatment requires a lot of patience and discipline from the patient.

Golfer’s elbow. And I don’t play golf!

“If you give up and lose your head you neither win nor live, and that’s just the way it is”

The Outlaw Josey Wales

Elbow pain and soreness is very common.  It seems to hit active and healthy people when they turn 40.  They symptoms usually start out as a pulling or discomfort in the arm but things can worsen to the point that routine activities can be difficult or almost impossible to do.  I’ve talked about tennis elbow, or tendinopathy  on the outside or lateral part of the elbow, and now I’d like to discuss it’s counterpart on the inside , or medial part of the elbow commonly called “golfers elbow”.  Tennis elbow is much more common than golfer’s elbow, but golfer’s elbow is a significant problem for the patients who get it.

Tennis elbow is usually called “lateral epicondylitis”, and golfer’s elbow is known as “medial epicondylitis”.  These terms are somewhat misleading.  In medical terms the four letters “itis” at the end of the word imply a form of inflammation, where tissues are irritated from a variety of causes.  In both tennis and golfer’s elbow the tendon tissues are really not inflamed, but instead seem to be degenerated.  The best thought at this time is that the tendons become damaged and your body is unable to heal the damaged tissue.

In golfer’s elbow the pain is usually located right on the bone on the inside of your elbow.  Several tendons attach here and they usually get irritated right at the point where they attach to the bone.  People have pain with grasping and activities that cause the wrist to bend down.  Golfers usually get pain right at impact when they hit the ball.  I can speak from personal experience that the pain can get pretty bad and cause you to have to lay off from golf and other aggravating activities for a period of time to rest the elbow.

In general I recommend conservative, non – surgical treatment for the problem.  Eventually the body can usually heal the damaged tendon if we just give it enough time.  Unfortunately a lot of people don’t want to wait or limit their activities long enough to let the problem heal, so there are some other things we can try.  Elbow stretches and light strengthening exercise can be very effective in decreasing pain.  Sometimes topical ointments such as compounding rubs with different types of medications in them can help as well.  Cortisone shots for the treatment of this problem are controversial.  I’ve looked at a lot of articles on this and had the personal experience of having cortisone shots into both sides of my right elbow, and I’ve come to the conclusion that cortisone probably won’t “cure” the problem any faster than exercises or rest, but the shot can sure get you through a rough past if you’re almost incapacitated from the problem.  If you’re a golfer then there are several things you can do to help prevent or treat the problem.  I think enemy #1 are the mats that many golf courses have you hit off on practice ranges during the winter.  Although the mats have some give they’re pretty hard underneath and I think the really stress the inside of your elbow.  I usually won’t hit more than 5 or 6 shots off a mat at any one time.  Another idea is to look at your shafts.  Graphite shafts have less stiffness and stress your arms less than steel.  It might be worth a look to see if changing shafts could help your arms.  Higher level players are reluctant to use graphite in their irons, but there are newer composite iron shafts of graphite and steel that seem to perform as well as pure steel shafts and may be an option.  Several tour pros have gone to the composite shafts so they are gaining in popularity.  Other people have suggested increasing your grip size, since this can theoretically decrease the amount of grip you place on the club and decrease the stress on your elbows.

If everything fails you can think about surgery.  Most surgeons would recommend waiting at least 6 months before considering surgery.  An open procedure where the damaged tendon tissue is directly removed is the most common treatment, but I have also used an ultrasound guided excision through a small incision.  This is known as the FAST procedure (F-focused A-aspiration of S-scar T-tissue).  I’ve done many more FAST procedures on tennis elbow than I have on golfer’s elbow, but I think it’s something to consider because of the potential for a quicker recovery.

The best advice to to try exercises and waiting this out as well as possibly modifying your equipment if you’re a golfer.  If that doesn’t help then injections and surgery are a reasonable thing to consider.