Acute Mallet Finger Injuries-A Review.

Acute disruptions of the terminal extensor tendon are common and can result in significant dysfunction if not recognized and treated appropriately. This article provides a topical review of the contemporary literature concerning acute mallet finger injuries. It also proposes a modification to the Doyle classification to make it more encompassing and less prone to interobserver error.

Prospective Randomized Clinical Trial Comparing 3-Point Prefabricated Orthosis and Elastic Tape Versus Cast Immobilization for the Nonsurgical Management of Mallet Finger.

PURPOSE: The purpose of this randomized trial was to compare the outcomes of using a 3-point prefabricated orthosis with elastic tape versus cast immobilization for the management of nonsurgical mallet finger. METHODS: This study was conducted in a single center. Individuals with a mallet injury requiring nonsurgical management were randomized to 6 weeks of full-time immobilization with either a 3-point prefabricated orthosis and elastic tape or a cast for distal interphalangeal joint extension. Outcomes were assessed at 12 weeks after the initiation of full-time immobilization and 6 months after injury. RESULTS: A total of 70 individuals agreed to participate in the study between April 2017 and April 2021. No statistically or clinically significant differences were found between the groups regarding distal interphalangeal joint extension lag, distal interphalangeal joint flexion deficits, function according to the brief Michigan Hand Outcome Questionnaire, and pain on the Numeric Pain Rating Scale. The overall findings for both treatment groups included means of <15° of extensor lag and minimal pain (mean, <1.2 of 10) at the 6-month outcome assessment. CONCLUSIONS: The use of a 3-point prefabricated orthosis with elastic tape and cast are both appropriate immobilization options for the management of nonsurgical mallet finger. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

A single K-wire to prevent poor outcomes in closed soft-tissue mallet finger management due to patient non-compliance.

INTRODUCTION: Soft-tissue mallet finger occurs due to loss of terminal extensor tendon secondary to rupture of distal phalanx. Although using noninvasive splints for 6-8 weeks is the gold standard for conservative treatment of closed soft-tissue mallet injuries, patient compliance is an important factor impacting on patient outcomes. In this study, we used a single Kirschner Wire (K-W) to fix the distal interphalangeal (DIP) joint in extension in those patients failed to comply with routine splinting. MATERIALS AND METHODS: In this prospective study, 190 patients with Doyle type 1 closed soft-tissue mallet finger deformity were included in four groups between 2011 and 2015. These groups were determined according to treatment modalities. Patients in the first group were treated with a finger splint (n = 109). Patients in the second group first received a finger splint and then K-W was applied due to lack of adequate compliance (n = 23). Patients in the third group were treated with K-W only (n = 47), and the fourth group did not accept surgical treatment nor conservative treatment (n = 11). After 20 weeks of follow up, we evaluated the results with functional measurements according to Crawford criteria and patient satisfaction. Additionally, the mid-term outcome was assessed with a follow-up at 2 years. RESULTS: At 20th week postoperatively, average DIP extension lag was 6 degrees (0-30) for the first group, 6.1 degrees (0-30) for the second group, 3.8 degrees (0-25) for the third group, and 17.3 degrees (7-30) for the fourth group. Total patient satisfaction was 85%, which was considered excellent or good. Swan neck deformity was observed in 11% of patients. Osteomyelitis and KW related complications were not observed. There were no statistically significant differences between short-term and mid-term results. CONCLUSION: Internal fixation via K-W may be a suitable treatment option compared to splint therapy for management of closed soft-tissue mallet finger in noncompliant patients. Using this treatment approach, the success rate for patients could satisfactorily be improved.

Outcomes of conservative treatment for bony mallet fingers.

BACKGROUND: The treatment strategy for bony mallet fingers remains controversial. The outcomes of conservative treatment were investigated in this study. In addition, the time to bone union, and gap between the bone fragment and distal phalanx are discussed. METHODS: The subjects were 26 patients (27 fingers) with bony mallet fingers (20 males and 6 females, mean age: 46.0 years old, the mean limitation of extension of the distal interphalangeal (DIP) joint: - 20.2°). In conservative treatment, splinting was applied for 6 weeks, followed by 2-week taping. The time to bone union, range of motion of the DIP joint, and the Crawford classification on the final follow-up were investigated. In addition, the bone fragment occupation rate was evaluated on plain radiography on the first examination. Furthermore, the gap on the first examination and after splinting. The relationship between the gap and bone union period was also investigated. RESULTS: The mean time from injury to bone union was 170.2 days, the mean range of motion of the DIP joint was - 8.5° in extension and 60.9° in flexion, and the Crawford classification was Excellent for 22 fingers, Good for 2, Fair for 2, and Poor for 1. On the first examination, the mean bone fragment occupation rate was 44.0%. The mean gap on the first examination was 1.1 mm and this was significantly narrowed to 0.8 mm after splinting (p < 0.01). No significant correlation was noted between the time to bone union and gap on the first examination (p = 0.16), however, a significant positive correlation was noted between them after splinting (p < 0.01). CONCLUSIONS: This study suggested that a favorable clinical outcome can be achieved by conservative treatment. Moreover, the bone union period decreased as the gap after splinting decreased, being significantly correlated.

A Paradigm Shift in Managing Acute and Chronic Boutonniere Deformity: Anatomic Rationale and Early Clinical Results for the Relative Motion Concept Permitting Immediate Active Motion and Hand Use.

BACKGROUND: We have utilized relative motion splinting for early motion following acute repair of boutonniere injuries, and we have developed nonoperative orthosis-based therapy for the treatment of chronic injuries. We offer our early clinical experience using relative motion flexion splinting for boutonniere deformities and explain the anatomic rationale that permits immediate active motion and hand use following acute injury or repair. For chronic boutonniere deformity, we offer a nonsurgical management method with low morbidity as a safe alternative to surgery. METHODS: Our understanding of the extrinsic-intrinsic anatomic interrelationship in boutonniere deformity offers rationale for relative motion flexion splinting, which is confirmed by cadaver study. Our early clinical results in 5 closed and 3 open acute and 15 chronic cases have encouraged recommending this management technique. For repaired open and closed acutely injured digits, we utilize relative motion flexion orthoses that place the injured digits in 15° to 20° greater metacarpophalangeal flexion than its neighboring digits and otherwise permit full active range of motion and functional hand use maintaining the 15° to 20° greater metacarpophalangeal flexion for 6 weeks. In fixed chronic boutonniere cases, serial casting is utilized to obtain as much proximal interphalangeal extension as possible (at least -20°), and then relative motion flexion splinting and hand use is instituted for 12 weeks. RESULTS: Our acute cases obtained as good as, or better range of motion than, conventional management techniques, with early full flexion and maintenance of extension without any recurrences. The most significant difference is morbidity, with ability to preserve hand function during healing and the absence of further therapy after 6 weeks of splinting. Patients with chronic boutonniere deformity presented from 8 weeks to 3 years following injury (averaging 31 weeks) and were 15 to 99 years of age (averaging 42 years). All were serially casted to less than -20° (averaging -4°) and maintained that level of extension after 3 months of relative motion flexion splinting. All achieved flexion to their palm, and all met the Steichen-Strickland chronic boutonniere classification of "excellent." There were no recurrent progressive boutonniere deformities in either acute or chronic cases and no instances of reflex sympathetic dystrophy/chronic regional pain syndrome (RSD/CRPS). CONCLUSIONS: Relative motion flexion splinting affords early active motion and hand use with excellent range of motion achieved following acute open boutonniere repair or closed boutonniere rupture with less morbidity than conventional management. Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension, and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion. No further therapy was needed in our cases. We believe this management technique should be attempted for chronic boutonniere deformity as a preferable alternative to surgery, which remains an option if needed.

Outcomes of Splinting in Pediatric Mallet Finger.

PURPOSE: Excessive flexion at the distal interphalangeal (DIP) joint disrupts the extensor mechanism, leading to mallet finger injuries. The goal of management is to restore active DIP joint extension. We sought to learn which variables (treatment technique, injury type, time to presentation, adherence to treatment) affect clinical outcomes of pediatric mallet finger injuries. METHODS: A retrospective review was performed of patients who presented with mallet finger injuries during 2013 to 2017 at a large pediatric hospital. Patient characteristics, treatments, outcomes, and radiographic data were collected. Types of nonsurgical treatment, acute versus delayed (> 28 days) presentation, and compliant versus noncompliant patients were compared. Differences in extension lag and incidence of complications were evaluated. RESULTS: There were 94 patients with 99 mallet fingers, with a mean age of 13.7 years, 66 of whom were boys (70%) and 28 girls (30%). Most injuries occurred during recreation (78%). Ninety-nine percent of patients were treated nonsurgically with extension orthoses. The majority of injuries were bony mallets (80%). The outcomes resulted in a mean extension lag of 1°. Of patients presenting acutely, residual extension lag and complications occurred in 12% and 9%, respectively; the lag and complication rate for patients presenting after a delay was 25% and 19%, respectively. Treatment adherence was associated with better clinical outcomes, with nonadherent patients more likely to experience a residual extensor lag (11% vs 67%) and potentially clinically relevant complications (8% vs 50%). CONCLUSIONS: The majority of pediatric mallet finger injuries can achieve good outcomes with nonsurgical treatment. Absolute indications for surgery in this population remain unclear. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

CURRENT TREATMENT OPTIONS OF DUPUYTREN´S DISEASE.

Dupuytren's disease (fibromatosis of the palmar fascia, benign neoplastic fibromatosis, Dupuytren's contracture) is a disease characterized by growth and successive contracture of single parts of the palmar aponeurosis. This condition is known and has been treated for several centuries. In the advanced stages of the disease, it leads to significant limitation of hand function, resulting in reduced quality of life of the patient. Dupuytren's disease (DD) is a life-long disease with a variable course and a heterogeneous clinical presentation. Therapy focuses on the clinical manifestations of the disease as well as on reduction of the functional limitation of the hand caused by the disease. In addition to conservative and surgical procedures, there are also some mini-invasive methods available. Treatment should be reserved for centres and experienced surgeons specialized in hand surgery.

Mallet Finger in a Toddler: A Rare But Easily Missed Injury.

A mallet finger is a flexion deformity of a finger at the distal interphalangeal joint due to an injury of the extensor mechanism at the base of the distal phalanx. Most common in middle-aged men, injuries in the pediatric population are less common and rare in toddlers. We describe a case of missed mallet finger and its subsequent treatment in a female toddler.

Adaptive shortening of long flexor in patients with claw hand: A short report.

Adaptive shortening of long flexors is the common secondary impairment which can occur in patients with long standing claw hand, particularly in those who do not undergo any supervised physiotherapy programme.¹ The main purpose of this short report is to describe the current physiotherapeutic means which are commonly employed for the management of long flexor tightness. This report further gives an insight into the consequences of the delay in corrective surgery and ultimately describes the dire need for further research on this deformity.² Adaptive shortening of the muscles is a phenomenon which can occur for many reasons, like prolonged immobilisation of the of the body segment, postural imbalance, muscle imbalance, impaired muscle performance due to neuromuscular problems or may be due congenital and acquired deformity.Tightness of the muscles leads to limitation of joint range of motion.³ In leprosy the cause of adaptive shortening of the long flexors is muscle imbalance which occurs due to paralysis of the ulnar nerve at the elbow joint. Adaptive shortening of the muscles is a secondary impairment.4 Secondary impairments have multidimensional effects on the management of the deformity, including delay in surgery for the correction of deformity which in turn is responsible for the unemployment, social stigma and problems in social integration.5 Secondary impairment in some way or other is responsible for the above stated problems, but adaptive shortening of the long flexor (long flexor tightness) is important because sometimes months of therapy are required to attain full muscle length.

ICF components of outcome measures for mallet finger: A systematic review.

STUDY DESIGN: Systematic review. INTRODUCTION/PURPOSE: The purpose of this study was to systematically review outcome measures used for the assessment of the conservative management of mallet finger to determine if they characterize the International Classification of Functioning, Disability, and Health components of activity, participation, environmental factors, or quality of life. METHODS/RESULTS: Five studies published within the last 10 years were included in the systematic review. A majority, 19 of the outcomes used by the authors, fell within the body functions and structures category. Six were related to activity, and 1 was related to participation. One was linked to environmental factors. Five were found to be not definable and related to quality of life. DISCUSSION/CONCLUSION: This systematic review suggests that many outcome measures focus on body structures and functions in the current research on the conservative treatment of mallet finger injuries. LEVEL OF EVIDENCE: 2a.

Management of the Acutely Burned Hand.

Despite contributing a small percentage to the total body surface area, hands are the most commonly burned body part and are involved in over 90% of severe burns. Although the mortality of isolated hand burns is negligible, morbidity can be substantial given our need for functioning hands when performing activities of daily living. The greatest challenges of treating hand burns are 2-fold. First, determining the depth of injury can be difficult even for the most experienced surgeon, but despite many diagnostic options, clinical examination remains the gold standard. Second, appropriate postoperative hand therapy is crucial and requires a multidisciplinary approach with an experienced burn surgeon, hand surgeon, and hand therapist. Ultimately, the goals of treatment should include preservation of function and aesthetics. In this review, we present an approach to the management of the acutely burned hand with discussion of both conservative and surgical options. Regardless of the initial treatment decision, subsequent care for this subset of patients should be aimed at preventing debilitating postburn scar contractures that can severely limit hand function and ultimately require reconstructive surgery.

Effects of a dynamic orthosis in an individual with claw deformity.

These authors describe their utilization of a dynamic orthosis to correct a strong claw deformity in a patient with a median and ulnar laceration. After 4 weeks of wearing the dynamic orthosis, these authors noted that the patient was able to actively extend all his fingers orthosis-free, with no evidence of claw.--Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Pachydermodactyly: a review.

Synovitis is the characteristic feature of inflammatory joint disease. If synovitis is localized to interphalangeal joints, rheumatoid arthritis, psoriatic arthritis, and juvenile idiopathic arthritis are among the most common differential diagnoses. The absence of pain, tenderness, and limitation of function despite progressive swelling of proximal interphalangeal joints suggests an alternative diagnosis, for example pachydermodactyly (PDD). This is a benign disease, associated with asymptomatic, progressive swelling of periarticular soft tissue, which usually occurs in young males. PDD is probably the result of repetitive mechanical stimulation. One hundred and twenty-one cases have been reported in the literature. Some of these were initially misdiagnosed and treated for inflammatory arthritis. We provide a comprehensive review of the literature on pachydermodactyly to promote awareness of this rare but important differential diagnosis of arthritis.

Closed soft tissue extensor mechanism injuries (mallet, boutonniere, and sagittal band).

The extensor mechanism of the hand is complex and can be disrupted at several different points, from hand trauma. This article summarizes current concepts relating to the presentation and treatment of closed soft tissue injuries of the extensor mechanism in zones I, III, and V, commonly known as mallet finger and boutonniere deformities and sagittal band injuries.

Tendon-bone graft for tendinous mallet fingers following failed splinting.

PURPOSE: To describe and assess a surgical technique for the treatment of tendinous mallet fingers after failed conservative treatment. METHODS: From January 2010 to March 2012, 28 tendinous mallet fingers in 28 patients were treated. All patients had greater than 25° extensor lags after 6 to 8 weeks of splinting. Four patients had a second trial of splinting, which also failed. A tendon-bone graft, taken from the extensor carpi radialis brevis and the third metacarpal base, was used for reconstruction. The mean time between the injury and operation was 74 days. The mean preoperative extension lag was 34°. Five patients reported pain in the distal interphalangeal joint. At the final follow-up, patients rated the level of pain on the distal interphalangeal and wrist joints using a visual analog scale. Joint motion was graded with the Crawford criteria. Hand function was assessed with the Disabilities of the Arm, Shoulder, and Hand questionnaire. Patients reported on their satisfaction based on the Michigan Hand Outcomes Questionnaire. RESULTS: Bone healing was achieved in all patients at a mean of 5 weeks. Position of bone graft was maintained until bone healing was evident in all cases. At the mean follow-up period of 15 months, nail deformity was not noted. No patient reported pain on the distal interphalangeal joint or wrist. The mean residual extension lag of the distal interphalangeal joints was 4°. The results showed that 24 digits were excellent and 4 were good based on the Crawford criteria. The Disabilities of the Arm, Shoulder, and Hand scores averaged 1, and 27 patients were satisfied with appearance of the hand. One patient sometimes felt uncomfortable regarding the appearance. CONCLUSIONS: A tendon-bone graft is a useful and reliable technique for the treatment of tendinous mallet fingers after failed splinting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Splinting and hand exercise for three common hand deformities in rheumatoid arthritis: a clinical perspective.

PURPOSE OF REVIEW: Hand deformities (ulnar drift, swan neck and boutonniere) are prevalent in rheumatoid arthritis and develop early in the disease process. These deformities cause significant functional impairment and impact quality of life. This review will provide a clinical perspective using the most recent evidence regarding the role of splinting and hand exercise in their management. The pathomechanics and functional consequences of these deformities are also described. RECENT FINDINGS: Patients tend to under-report their hand problems and are often reluctant to seek treatment for their deformities. There is limited evidence to support or refute the role of splinting and hand exercises in their management. Clinical experience suggests splinting and hand exercise are most beneficial when prescribed for early, flexible deformities. SUMMARY: More research is required to guide clinicians on the most effective approach to the management of these three hand deformities. It is imperative that clinicians assess for and recognize these deformities in order to ensure timely and appropriate treatment. Until more evidence becomes available, an evidenced-informed approach is recommended.

Prevalence and clinical characteristics of dactylitis in spondylarthritis: a descriptive analysis of 275 patients.

OBJECTIVES: Dactylitis is a common but little studied feature of spondylarthritis (SpA). Our objective was to assess the prevalence of dactylitis among a cohort of patients with spondylarthritis in a tertiary care centre and to describe the clinical characteristics of dactylitis. METHODS: This was a prospective single centre observational study carried out in 2010. The patients included had been diagnosed as having definite SpA based on Amo's criteria. Each patient was interviewed by a physician. The data collected included prevalence of dactylitis and its clinical characteristics, effectiveness of the different treatments, and association with severe manifestations of SpA, and analysed by descriptive analysis. RESULTS: 275 consecutive SpA patients were assessed: mean age 43.2±13.5 years, mean disease duration 14.0±11.8 years, 169 (61.4%) were men. In all, 59 patients (21.5%) suffered from SpA-associated dactylitis. The localisation of dactylitis was toes in 46 patients (78.0%) and/or fingers in 25 patients (42.4%). The most frequent localisations were the second toe and the second finger. Dactylitis was the first symptom of SpA in 14 patients (5.1%), and 28.8% (n=17) of dactylitis appeared within the first 5 years of disease. Dactylitis was present in 35.1% (n=13) of patients with undifferenciated SpA and in 30.6% (n=15) of patients with psoriatic arthritis. It was significantly associated with history of peripheral arthritis or heel pain. In our population, there was no correlation between dactylitis and HLA B27 status or sex and it was not a marker of severity of disease. CONCLUSIONS: Dactylitis is a frequent manifestation in SpA (21.5%) particularly in peripheral disease and it may be the first manifestation of the disease with localisation being more frequent in the toes.

[Erosive hand osteoarthritis]. / Arthrose digitale érosive.

Erosive hand osteoarthritis is a form of hand osteoarthritis. Phase of the normal process or separate entity? This remains debated. It is defined by radiographic erosions with a central subchondral bone collapse. It is more frequent than initially described as recently evidenced by ultrasonographic and MRI images which have shown better sensitivity to detect erosions and osteophytes than conventional radiographs. Synovitis, detectable by Doppler ultrasonography, is a common feature. The classical clinical picture is made of inflammatory flares with severe pain, joint swelling and important functional impairment. It leads to severe joint destruction, with major deformations and sometimes ankylosis with mobility restriction. It carries high consequences in terms of aesthetic discomfort, functional impairment and impact on quality of life, justifying the earliest diagnosis as possible and a tight management using, among many other options, local and general anti-inflammatory therapeutics.

Mallet Finger: Two Different Injuries.

Mallet injuries, either tendinous or bony, are common. They are often studied together and typically treated in the same way with extension splintage for 6 to 8 weeks. Yet the evidence clearly shows there are different injuries that present in the same way. Tendinous mallet injuries present in older patients usually following a low energy injury; they are often painless. The commonly injured fingers are the middle and ring. The injuries are almost always single digit without concomitant injuries. There is an extensor lag of a mean of 310 (range 3°-590) in the patients treated in my unit. In contrast, bony mallet injuries occur at a younger age (mean 40 years) and are always due to high energy injuries. The injuries are always painful. The commonly injured fingers are the ring and little fingers. There are multiple injuries in 3% (range 2%-5%) and in 4% to 8% of cases, there are concomitant (nondigital) injuries according to data in my unit. Radiologically there is an appreciably smaller extensor lag; mean 130 (range 0°-400). In particular, bony mallet injuries are extension compression, not avulsion, fractures which should not logically be treated with an extension splint which will reproduce the direction of injury.

Effectiveness of Quickcast Versus Custom-Fabricated Thermoplastic Orthosis Immobilization for the Treatment of Mallet Fingers: A Randomized Clinical Trial.

BACKGROUND: Mallet finger is a common injury involving a detachment of the terminal extensor tendon from the distal phalanx. This injury is usually treated with immobilization in a cast or splint. The purpose of this study is to compare outcomes of mallet fingers treated with either a cast (Quickcast) or a traditional thermoplastic custom-fabricated orthosis. METHODS: Our study was a prospective, assessor-blinded, single-center randomized clinical trial of 58 consecutive patients with the diagnosis of bony or soft tissue mallet finger treated with immobilization. Patients were randomized to either an orfilight thermoplastic custom-fabricated orthosis or a Quickcast orthosis. Patients were evaluated at 3, 6, and 10 weeks for bony and 4, 8, and 12 weeks for soft tissue mallets. Skin complications, pain with orthosis, compliance, need for surgical intervention, and extensor lag were compared between the 2 groups. RESULTS: Both bony and soft tissue mallet finger patients experienced significantly less skin complications (33% vs 64%) and pain (11.2 vs 21.6) when using Quickcast versus an orfilight thermoplastic custom-fabricated orthosis. The soft tissue mallet group revealed a greater difference in pain, favoring Quickcast (6.2 vs 22). No significant difference in final extensor droop or need for secondary surgery was found between the 2 groups. CONCLUSIONS: Quickcast immobilization for the treatment of mallet finger demonstrated fewer skin complications and less pain compared with orfilight custom-fabricated splints.