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Risk for Infection

It is very important to seek immediate attention if there is blood beneath the nail or if the nail is detached. This may be a sign of a cut in the nail bed, or that the finger bone is broken and the wound penetrates (extends) down to the bone (open fracture). These types of injuries put you at risk for infection.

First Aid

• To relieve pain and reduce swelling, apply ice to your finger immediately and keep your hand elevated above your heart.
• Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen and naproxen, may help with the pain.
• You can create a well-padded splint for the tip of the digit, but make sure the splint is not so long that it prevents motion of the uninjured joints.
• Seek an evaluation with a hand surgeon as soon as possible, ideally within a week of the injury.

Physical Examination

After discussing your medical history and symptoms, your doctor will examine your finger or thumb. During the examination, your doctor will hold the affected finger and ask you to straighten it on your own. This is called the mallet finger test.

During a mallet finger test, your doctor determines whether you can straighten your fingertip without assistance.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

X-rays

Your doctor will most likely order X-rays of the injury.

If a fragment of the distal phalanx was pulled away when the tendon ruptured, or if there is some other larger fracture of the bone, it will appear in an X-ray.

An X-ray will also show whether the injury pulled the bones of the joint out of alignment, which may require surgery to correct.

X-ray shows that a piece of the distal phalanx bone broke away with the tendon.

Nonsurgical Treatment

Most mallet finger injuries are treated with splinting. A splint holds the fingertip straight (in extension) until it heals.

There are several types of splints used to treat mallet finger, many of them fabricated (made) by hand therapists.

Reproduced from Culver JE Jr: Office management of athletic injuries of the hand and wrist. Instr Course Lect 1989;38:473-482.

To restore function to the finger, the splint must be worn full time for 6 to 8 weeks. This means that it must be worn while bathing, then carefully changed afterward. However, the splint can be removed for bathing if the DIP joint (finger) or IP joint (thumb) is held straight with the other hand the entire time the splint is off. If the fingertip droops at all, healing is disrupted, and you will need to wear the splint for a longer period of time.

Because wearing a splint for a long period of time can irritate the skin, your doctor may talk with you about how to carefully check your skin for problems. Your doctor may also schedule additional visits over the course of the 8 weeks to monitor your progress.

When removing the splint for cleaning and drying, the fingertip must stay in extension.

For 3 to 4 weeks after the initial splinting period, you will gradually wear the splint less frequently — perhaps only at night. Splinting treatment usually results in both acceptable function and appearance; however, many patients do not regain full fingertip extension.

A temporary splint is applied with two pieces of tape.

For some patients, the splinting regimen is very difficult. In these cases, the doctor may decide to insert a temporary pin across the fingertip joint to hold it straight for 8 weeks.

Surgical Treatment

Your doctor may consider surgical repair if there is a large avulsion fracture fragment, or the joint is out of line (subluxed). In these cases, surgery is done to repair the fracture and realign the joint using pins to hold the pieces of bone together while the injury heals.

As mentioned above, surgery may also be considered if you are unable or unwilling to wear a splint for 8 weeks. Pinning the joint straight acts like an internal splint; however, this comes at the cost of increased risk for complication with surgery.

If there is no fracture and the joint is well-aligned, it is not common to treat mallet finger with surgery. The tendon is very thin, and repairs with suture are difficult, if not impossible. Tendon grafts — taking tendon from another part of the body and applying it to the damaged finger — are challenging and not always effective. Thus, splinting is usually the treatment of choice.

In a chronic mallet finger (the injury is several months or years old), fusion of the joint may be considered. A joint fusion removes the movement in the joint and positions it in a permanent, useful position. For the DIP and IP joints, the fusion is often done fairly straight for appearance and function.