“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.