Figure 1: Terminal extensor tendon avulsion at distal interphalangeal joint of 5th digit
A 17-year-old baseball player presents complaining of finger pain and difficulty straightening his finger after a baseball game. You obtain x-rays and see the following fracture (photo credit).
What is your diagnosis and emergency department management?
- Mallet Finger, Baseball finger, or Hammer finger are all common names for this injury. It is an injury to the terminal extensor tendon at the distal interphalangeal joint.1
- This is typically the result of an axial loading injury with the finger or thumb in extension forcing the joint into flexion and may be accompanied with an intra-articular avulsion fracture.2 This may also commonly result from a dorsal laceration.
Figure 2. Typical appearance of mallet finger of 2nd digit (photo credit)
- In the ED, acute mallet finger injuries are evaluated with plain radiographs.
- The preferred management for mallet finger with and without avulsion fracture is non-operative treatment.1-3
- Splint the DIP in neutral while maintaining free movement of the PIP joint. Volar splinting is preferred over dorsal splinting. Avoid hyperextension. See more examples of good examples of DIP splinting.
Discharge with an extension splint (ensure free PIP movement) and follow up with primary care or sports medicine physician. The splint should be worn for at least 6 weeks. Conservatively this means 6 weeks of 24 hours splinting followed by 2-6 weeks of nighttime splinting depending on symptoms.1,4
- Never, unless it is an open fracture or involves neurovascular compromise.
- Absolute indication: Volar subluxation of the distal phalanx
- Relative indications: Avulsion fracture greater than a third of the intra-articular joint, >2 mm displacement, and complex injuries1-5
- Complications: Skin sloughing, extensor lag, and swan-neck deformity may eventually require surgical management3-5
Read more on ALiEM about extensor tendon injuries.
For more cases like these, you can subscribe to the Ortho EM Pearls email series hosted by Drs. Will Denq, Tabitha Ford, and Megan French, who have kindly shared some of their content with ALiEM.
References
- Lamaris, Gregory A., and Michael K. Matthew. The Diagnosis and Management of Mallet Finger Injuries. Hand. 2016;12(3):223–228. https://www.ncbi.nlm.nih.gov/pubmed/28453357
- Bachoura A, Ferikes AJ, Lubahn JD. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017;10(1):1-9. https://www.ncbi.nlm.nih.gov/pubmed/28188545
- Megerle K, Prommersberger KJ. Chapter 10 – Extensor tendon injuries. In: James Chang, Peter C. Neligan. Plastic Surgery: Volume 6: Hand and Upper Extremity (2017). New York: Elsevier; 2017:227-246.
- Sreenivasa R. Alla, Nicole D. Deal, Ian J. Dempsey. Current Concepts: Mallet Finger. Hand. 2014;9(2):138-144. https://www.ncbi.nlm.nih.gov/pubmed/24839413
- Wieschhoff GG, Sheehan SE, Wortman JR et-al. Traumatic Finger Injuries: What the Orthopedic Surgeon Wants to Know. Radiographics. 2016;36(4):1106-1128. https://www.ncbi.nlm.nih.gov/pubmed/27399238
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