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The mallet finger is a common hand injury in sports with ball use. Here, we present the case of a goalkeeper with simultaneous bilateral mallet fingers in the third and fourth ray, successfully treated with splinting. Origin and treatment options are discussed.

Mallet finger is a common injury involving either an extensor tendon rupture at its insertion or an avulsion fracture involving the insertion of the terminal extensor tendon. It is usually caused by a forceful blow to the tip of the finger causing sudden flexion or a hyperextension injury. Fracture at the dorsal aspect of the base of the distal phalanx is commonly associated with palmar subluxation of the distal phalanx. Most mallet finger injuries are recommended to be treated with immobilisation of the distal interphalangeal joint in extension by splints. There is no consensus on the type of splint and the duration of use. Most studies have shown comparable results with different splints. Surgical fixation is still indicated in certain conditions such as open injuries, avulsion fracture involving at least one third of the articular surface with or without palmar subluxation of the distal phalanx and also failed splinting treatment.

Introduction: To identify the strongest peak load resistance among four mallet finger fracture fixation methods (Kirschner wire, pull-out wire, tension-band wiring and the JuggerKnot™ (Biomet) soft anchor fixation).

Methods: Fixation techniques were assigned among 24 specimens from six cadaveric human hands in a randomized block fashion. Peak load resistance was tested at 30°, 45° and 60° of flexion of the distal interphalangeal joint.

Results: The mean peak load of tension-band wiring was 67.8 N at 60° of flexion which was most superior. The JuggerKnot™ fixation had mean peak loads of 13.35 N (30°), 22.51 N (45°) and 32.96 N (60°). No complications of implant failure or fragmentation of the dorsal fragment was noted.

Conclusions: Tension-band wiring was the strongest fixation method but was most prominent on the skin surface as seen in three specimens. The JuggerKnot™ soft anchor fixation had similar peak load resistance as k-wire fixation and pull-out wiring.

Unlike mallet finger, mallet thumb is rare. We treated a case of mallet thumb with avulsion fracture using extension block Kirchner wire technique, and achieved excellent results.

Swan neck deformity (SND) can be the manifestation of an acute trauma. We present a case report of a young basketball player with an acute traumatic SND determined by the single ulnar oblique retinacular ligament rupture. The patient caught a ball directly upon the tip of his right’s hand middle finger into extension. He immediately presented a SND with impossibility to actively flex the proximal interphalangeal joint (PIPJ), while preserving active flexion and extension of the distal interphalangeal joint (DIPJ). Hyperextension of PIPJ was reducible with passive mobilization, thus allowing full passive range of motion. The SND was seen to be caused by the lesion of the ulnar oblique retinacular ligament (ORL) on its distal insertion, with consequent dorsomedial migration of the ulnar lateral band. The early surgical distal reinsertion of the ORL allowed the restoration of the original kinematics of the finger flexion-extension.

We describe three steps to aid fracture assessment and fixation in the extensor block pin technique for mallet fractures. The first step is the use of fluoroscopy in the initial assessment to determine indication for fixation. Next is the use of supplementary extension block pin to control larger dorsal fragments. The third technique described details the steps of open reduction of nascently malunited fractures.

Background: The vast majority of acute closed tendinous mallet injuries are treated with a splint. Very few studies have directly compared splinting versus pinning the distal interphalangeal joint for this injury. The aim of this cohort study is to determine the outcomes of both methods.

Methods: A total of 59 patients with acute tendinous mallet injury were retrospectively enrolled (29 patients in conservative treatment and 30 patients in surgical treatment). Conservative treatment was performed using custom-made thermoplastic splint and surgical treatment was conducted with oblique K-wire fixation of the distal interphalangeal (DIP) joint. The DIP joint was immobilized for eight weeks in both treatments. Active ranges of motion of the affected finger and Miller’s classification were evaluated postoperatively.

Results: The mean extension lag of the DIP joint in the surgical treatment group was significantly better than it was with conservative treatment (2.1° vs 13.8°). Three patients who were noncompliant with the splint showed poor results, while no patients in the surgical treatment group had a poor result.

Conclusions: Surgical treatment with K-wire fixation leads to satisfactory results for acute tendinous mallet injury.

A mallet finger is a common injury that results from a sudden flexion force on an extended distal phalanx or rarely, from hyperextension of the distal interphalangeal joint. Mallet finger can be purely tendinous or bony when associated with an avulsion fracture. The management of this injury is largely conservative with the use of a splint, although surgery may be indicated for select patients. There is little consensus on the indications for surgery or the suitable surgical technique. The aim of this review article is to provide a pragmatic and evidence-based approach to mallet finger that will guide the treating surgeon in providing best care for their patient.

Background: Stack splint is commonly used for mallet finger treatment but patients had a tendency to frequently remove it because of skin complications. We hypothesized that a comprehensively instructed splinting regime would increase patients’ compliance and lead to favorable outcomes with fewer skin complications. The aims of this study were to assess the patients’ compliance and to evaluate outcomes with that particular splinting regime.

Methods: Forty-six consecutive patients were enrolled in this prospective study. They were instructed to wear the Stack splint for 24 hours a day every day in the first six weeks and remove it once a day for 10 minutes to vent. They were told to support distal interphalangeal joint volarly both while wearing the splint and when it was removed. Free movement of proximal interphalangeal joint within the splint was checked after each application. Following whole-day regime for 6 weeks, night splinting continued for 2 more weeks. Range of motion, skin complications, patients’ compliance and satisfaction were assessed at last follow-up.

Results: There were 26 patients with a mean age of 39.8 and mean follow-up period of 6.7 months. No skin complications or proximal interphalangeal joint stiffness were reported. However, nine patients declared that they wore the splint ≤ 4 weeks, the compliance rate to our regime was 65.4% (17/26). In the 17 fully compliant patients, mean distal interphalangeal joint extension lag was 12.4 and nine of them (52.9%) were satisfied with the outcome.

Conclusions: Our both hypotheses failed; comprehensive instructions for the splinting regime did not improve patients’ compliance satisfactorily, nor did it lead to favorable outcomes. Although Stack splint has practical points, we no longer use it.

Background: The purpose of this study was to compare percutaneous pinning versus splinting of soft tissue mallet finger injury to determine if there are differences in residual extensor lag and complication rates.

Methods: Patients ≥18 years of age undergoing mallet finger injury treatment from 2011 to 2020 were retrospectively reviewed. Exclusion criteria included bony or open mallet finger injury and incomplete documentation of residual extensor lag at final follow-up. Complications, including infection, hardware fixation failure and wound complications, were collected from follow-up clinic notes. Those treated with percutaneous pinning were compared to those treated non-surgically with splinting.

Results: Of the 150 soft tissue mallet finger injuries that met the inclusion criteria, 126 were treated with splinting, and 24 were treated with percutaneous pinning. There were no differences in residual extensor lag between groups (Splinting: 5.4°, Pinning: 5.8°, p = 0.874). However, the pinning group had a higher overall complication rate than the splinting group (20.8% vs. 1.6%, p = 0.001).

Conclusions: Surgery may be an effective treatment method for soft tissue mallet finger, but due to the higher rate of complication and the increased expense of a surgical procedure, splinting should be the preferred treatment method for most of these injuries.

Level of Evidence: Level III (Therapeutic)

The best treatment for mallet fingers is still a matter of debate. Numerous splints with different designs to keep the distal interphalangeal (DIP) joint in extension have been described in literature. The outcomes of splint treatment are generally good with occasional reports of minor skin complications. Percutaneous Kirschner-wire pinning of the DIP joint for closed tendinous mallet finger represents a alternative treatment modality that reliably immobilises the joint and does not need much patient compliance or use of an external splint. We report a rare but devastating complication of percutaneous pinning of the DIP joint for closed tendinous mallet finger.

Level of Evidence: Level V (Therapeutic)

Background: Surgery is often offered to patients with mallet fractures that have a large, displaced fragment and/or joint subluxation. However, the surgical approach remains a subject of debate, and surgery is frequently associated with unsatisfactory outcomes. We felt that the angle formed by the fracture line and the long axis of the distal phalanx on a lateral view radiograph (fracture line angle [FLA]) could be useful in determining the appropriate treatment strategy. The aim of this study was to assess the FLA and its distribution in mallet fractures.

Methods: Three researchers measured the mallet FLA and the percentage of articular surface (PAS) involved in the lateral radiographs of 103 patients with a mallet fracture.

Results: There was a strong correlation between the mallet FLA and the percentage of joint surface involvement between the three researchers. The mean FLA was 42.59° (±11.54) and it ranged from −1 to +1 standard deviation in 73 individuals (70.87%). The FLA varied over a wide range, while clustering near the average value. The average PAS involvement was 46.5% (±8.7%). There was no correlation between FLA and PAS involvement (p > 0.05).

Conclusions: It is possible to quantify the mallet FLA accurately and consistently. It varies widely, regardless of the PAS involvement. When choosing the type of treatment and making prognostic predictions, the mallet FLA may be a helpful guide.

Level of Evidence: Level IV (Diagnostic)