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.

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.

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.

An overview of mallet finger injuries.

Mallet finger describes a fingertip deformity where the distal interphalangeal joint (DIPJ) of the affected digit is held in flexion, unable to extend the distal phalanx actively. The deformity is typically a consequence of traumatic disruption to the terminal extensor tendon at its insertion at the proximal portion of the distal phalanx or slightly proximally at the level of the DIPJ. Patients typically present with a history describing the event of injury with a typical mallet deformity. Common mechanisms include sport activities causing a direct blow to the finger, low energy trauma while performing simple tasks such as pulling up socks or crush injuries from getting the finger trapped in a door. The DIPJ can be passively extended, but this extension of the joint cannot be maintained once the passive extension is stopped. The Doyle classification can be used to categorise and dictate treatment. The extensor lag associated with the deformity does not improve spontaneously without treatment. Inappropriate management can lead to chronic functional loss and stiffness of the finger. The majority of closed mallet splints are Doyle type I, which can be managed non-surgically with external splints, worn full-time to keep the fingertip straight until the tendon injury or fracture heals. Surgical techniques is considered for other types of mallet injuries. Techniques used include closed reduction and Kirschner wire fixation, open reduction and internal fixation, reconstruction of the terminal extensor tendon and correction of swan neck deformity.

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 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.

Optimising the conservative management of closed tendinous mallet finger injury.

Mallet finger injuries are a common presentation in the emergency department. These injuries result from a forced flexion at the distal interphalangeal joint (DIPJ) that causes extensor tendon disruption, and possibly bone avulsion, at the base of the distal phalanx. This article describes the anatomy, mechanisms, classification and assessment of mallet finger injury. It reviews different types of splints used in the conservative management of closed tendinous mallet finger injury and discusses the latest evidence regarding immobilisation methods and treatment duration. Maintaining the DIPJ in extension during treatment is essential, so the article stresses the importance of patient adherence to treatment.

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.

Mallet Finger Lattice Casts Using 3D Printing.

Currently, research based on the technology and applications of 3D printing is being actively pursued. 3D printing technology, also called additive manufacturing, is widely and increasingly used in the medical field. This study produced custom casts for the treatment of mallet finger using plaster of Paris, which was traditionally used in clinical practice, and 3D printing technology, and evaluated their advantages and disadvantages for patients by conducting a wearability assessment. Mallet finger casts produced using plaster of Paris, when incorrectly made, can result in skin necrosis and other problems for patients. These problems can be mitigated, however, by creating casts using 3D printing technology. Additionally, plaster casts or ready-made alternatives can be inconvenient with respect to rapid treatment of patients. In contrast, 3D-printed casts appear to provide patients with appropriate treatment and increase their satisfaction because they are small in size, custom-made for each patient, and can be quickly made and immediately applied in clinical practice.

Mallet Finger.

This article provides an overview of issues associated with traumatic injury to the distal finger that results in extensor tendon disruption or bony avulsion at the base of the distal phalanx. Commonly referred to as mallet finger, drop finger, or baseball finger, terminal extensor tendon injuries are a common presentation to the emergency department. Providers need to be advised of evidence-based management of these extensor tendon injuries in order to prevent decreased function and permanent deformity. Current evidence supports nonoperative interventions, but injuries need to be addressed in a timely manner in order to avoid poor outcomes.

Managing Swan Neck and Boutonniere Deformities.

Acute and chronic injuries to the finger extensor mechanism can result in swan neck and boutonniere deformities. Loss of coordination between the multiple, specialized components of the extensor mechanism results in tendon imbalances leading to altered interphalangeal joint flexion and extension forces. Treatments include corrective splinting and operative interventions. Swan neck deformities are functionally limiting. Surgical correction generally results in functional benefit. Boutonniere deformities are functional but aesthetically displeasing; proximal interphalangeal (PIP) joint flexion and the ability to make a fist are maintained. Surgical improvement can be attempted with caution. Attempts to improve PIP extension can impede flexion, resulting in a poor functional outcome.

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.

Comparison of Treatment Results for Mallet Finger Fractures in Children Between Low-Intensity Pulsed Ultrasound Stimulation and Ishiguro's Method.

BACKGROUND: We compared the treatment results for displaced mallet finger fractures in children between low-intensity pulsed ultrasound (LIPUS) stimulation and Ishiguro's method, which involves extension block and arthrodesis of the distal interphalangeal (DIP) joint with pinning. METHODS: Eleven cases (5 females and 6 males; average age, 13.5 years) of mallet finger were operated with Ishiguro's method, and 8 cases (3 females and 5 males; average age, 13.0 years) were treated with LIPUS stimulation. Lateral radiographs were used to determine the distance of fragment displacement and the percentage of the articular surface involved in the fragments. Functional outcomes in flexion and extension and those estimated using Crawford's evaluation criteria at the final visits were assessed in each group. RESULTS: The duration needed for fracture healing was longer, however, active extension and flexion of the DIP joint were significantly larger in the LIPUS group compared with those in the pinning group. Functional recovery was excellent in all cases in the LIPUS group; however, recovery was good in 3 cases and excellent in 8 cases in the pinning group. Extension of the DIP joint was significantly larger when pins were removed in 35 or lesser days postoperatively compared with cases in which pin fixation was continued for more than 35 days. CONCLUSIONS: LIPUS therapy may be recommended as an option to treat type I mallet finger in children for whom initiation of treatment was delayed up to 8 weeks. When Ishiguro's method is applied to the displaced mallet fracture in children, arthrodesis of the DIP joint for more than 5 weeks should be avoided to prevent flexion contracture.

[Deformities of the finger joints].

Extension of the fingers is a complex act. Boutonnière deformity is defined by flexion at the proximal inter-phalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint due to disruption of the central slip of the extensor tendon. Swan neck deformity is defined by hyperextension at the PIP joint and flexion at the DIP joint, and the pathology is divided into intrinsic, extrinsic, and articular. The deformities are a result of imbalance of the tendons and ligaments in the fingers. Treatment is depending on the underlying cause and includes surgery and non-operative treatment. Functional gain and risk must be realistically assessed.

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.

Reconstrução tardia na mão traumatizada com perda de múltiplos dedos / Late reconstruction of a traumatized hand with loss of multiple fingers

As lesões mutilantes de mão são um desafio para o cirurgião de mão e o paciente. O cirurgião deve tomar decisões desde o debridamento inicial, escolhendo quais dedos e articulações serão preservadas e uso apropriado das partes a serem retiradas. A reconstrução tardia é a segunda parte dessa difícil tarefa. Dificuldade que se atribui à particularidade de cada lesão, do grande número de possibilidades de tratamento e seus diversos níveis de complexidade que devem ser adequados à necessidade e motivação pessoal de cada paciente. Este relato de caso apresenta uma reconstrução tardia de mão com perda de indicador e dedo médio com transplante de articulação metacarpofalângica de indicador para função de interfalangeana proximal de dedo médio.

Mutilating hand injuries are a challenge to both the hand surgeon and the patient. The surgeon must make decisions ranging from the initial debridement to which fingers and joints will be preserved and the appropriate use of the parts to be removed. Late reconstruction constitutes the second part of this difficult task. The difficulty attributed to the characteristics of each lesion, the large number of treatment possibilities, and the different levels of complexity must be adapted to the personal needs and motivation of each patient. This case report describes a late hand reconstruction with index and middle finger loss, using metacarpophalangeal joint transplantation of the index finger to gain the proximal interphalangeal function of the middle finger.

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.

State of the art. Autologous fat graft and adipose tissue-derived stromal vascular fraction injection for hand therapy in systemic sclerosis patients.

Systemic sclerosis is an autoimmune disease characterized by sclerosis (hardening) of the skin and deep viscera associated with microvascular functional and structural alteration, which leads to chronic ischemia. In the hands of patients, ischemic and fibrotic damages lead to both pain and functional impairment. Hand disability creates a large burden in professional and daily activities, with social and psychological consequences. Currently, the proposed therapeutic options for hands rely mainly on hygienic measures, vasodilatator drugs and physiotherapy, but have many constraints and limited effects. Developing an innovative therapeutic approach is crucial to reduce symptoms and improve the quality of life. The discovery of adult stem cells from adipose tissue has increased the interest to use adipose tissue in plastic and regenerative surgery. Prepared as freshly isolated cells for immediate autologous transplantation, adipose tissue-derived stem cell therapy has emerged as a therapeutic alternative for the regeneration and repair of damaged tissues. We aim to update literature in the interest of autologous fat graft or adipose derived from stromal vascular fraction cell-based therapy for the hands of patients who suffer from systemic sclerosis.