Jeanine Beasley, EdD, OTR, CHT, FAOTA

Professor, Grand Valley State University

Grand Rapids, Michigan

2019 Philadelphia Meeting

Conservative Management of

Mallet, Swan Neck, and

Boutonniere

Mallet Finger• The extensor tendon is cut or torn

from the insertion on the distal

phalange.

• Common causes: sudden, direct

impact to the end of the finger and

hyperextension - basketballs,

footballs, and baseballs.

• Everyday household activities such

as making the bed, doing laundry,

etc.

Diagnosis• Type 1- Result of blunt trauma.

Tendon damage may or may not be

associated with small avulsion

fracture.

• Type 2- Result of complete rupture

or laceration of the tendon.

• Type 3- Result of deep abrasion.

• Type 4- Fractures involving more

than 20% of the articular surface in

adults with greater than 50% volar

subluxation of distal phalanx.

Treatment• If left untreated, mallet finger can

lead to a swan neck deformity.

• Patient compliance is essential

• Orthosis alone - Type 1 injury

• Orthosis is also used post-

operatively to protect the repaired

tendon.

• Surgical treatment is used more

often in Type 2 through 4 injuries

and in severe cases.

• Surgery also is indicated when the

person delays treatment.

Orthotic Preferences• Cook, et al. (2017).

How do hand therapists conservatively manage acute, closed mallet finger? A survey of members of the British Association of Hand Therapists. Hand Therapy, 22 (1) 13-25.

• Custom orthoses was the favored option

• 6-8 weeks immobilization

• Weaning with

removable orthosis

standard practice

Rolyan Quickcast "2"

Custom mallet orthoses had fewer skin complications (Witherow & Peiris, 2015)

Weaning from the orthosis

• Lag increases after discontinuation of the orthosis

(Pike, et al., 2010)

• Lag is worse as age increases

(Pike et al., 2010)

• Weaning with removable orthosis standard practice.

(Cook, et al., 2017)

• Orthosis to be worn at night, heavy loading.

• Weaning up to 12 weeks (mode = 4 weeks)

• Avoid DIP PROM 10-12 weeks

Tape Support Under the Orthosis During

Donning and Removal

• Elastic tape (Devan, 2018)

• Steri-strip (Mak, et al., 2016)

If Swan Neck is Developing

• Include the PIP joint

in the orthosis -

flexion

Boutonniere and Swan Neck• The proximal interphalangeal joints are among the most

commonly injured joints of the hand (Chinchalker & Bing, 2003)

• Swan neck and boutonniere deformities are common in

Rheumatoid arthritis (P. Feldon, Terrono, Nalebuff, Millender, 2005).

• Swan neck deformities have also been reported in Ehler

Danlos syndrome (Erçöçen, Yenidünya, Yilmaz, Ozbek, 1997) and benign

hypermobility syndrome (Lawrence, 2005).

The

Delicate

Balance

Swan-neck: RA, Ehler Danlos syndrome,

Cerebral Palsy, Benign Hypermobility

Syndrome, and Trauma

Orthoses and the Swan-neck Deformity

• Zijlstra, T.R, HeijnsdijkRouwenhorst, L., & Rasker, J. J. (2004). Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis &Rheumatism, 51(6), 947-951.

• Spicka C, Macleod C, Adams J, Metcalf C. Effect of silver ring splint on hand dexterity and grip strength in patients with rheumatoid arthritis: an observational pilot study. Hand Therapy. 2009; 14: (2): 53-7.

• Tar Schegget M; Knipping A. A study comparing use and effects of custom-made versus prefabricated splints for swan neck deformity in patients with rheumatoid arthritis. British Journal of Hand Therapy. 2000; 5(4): 101-7.

Oval 8 Splints: One time adjustment!

Patients prefer prefabricated splints for swan neck deformity in RA - Oval 8, Silver Ring Splints, etc. (Tar Schegget, et al. 2000)

Trauma: Swan Neck and Dorsal

PIP Joint Dislocation

• Pinned in 20° flexion for 2 weeks (4 weeks with CP)

• Replaced with dorsal blocking orthosis

• Active flex/ext in the orthosis-distal strap detached

• Wean from orthosis at 6 weeks

Fox & Chang (2018)

Tenodesis: Postoperatively

(Fox & Chang, 2018)

• 2 weeks post digit or

hand based dorsal

blocking orthosis

• AROM in the DBO

–distal straps

removed

• 6 weeks post:

weaned from

orthosis

Boutonniere

• Acute, nonsurgical

• Open acute, post surgical

• Chronic, non surgical

• Chronic, post surgical

• Initiation of active movement various in

the literature based on condition

Boutonniére Deformity Diagnostic Tests

Boyes Test

(negative)

Active flexion of

DIP joint is limited

when PIP joint is

passively positioned

in full extension.

Modified Elson Test (positive)

PIP in 90-degrees flexion.

This normally keeps the central band taut and the lateral

bands loose.

Ask the patient to extend the PIP, while the provider’s

finger applies counterforce at the middle phalanx.

NORMAL Elson’s test: Results in active extension of the

PIP joint and a floppy DIP.

ABNORMAL Elson’s test: Results in no active extension

of the PIP joint and a slightly extended, taut DIP.

Boutonniere Deformity

• Chronic: attempt serial casting

• Fractures some start gentle

motion 3 weeks after fracture

reduction

• Depending on the soft tissues

delay gentle motion 6 weeks

• Active DIP motion only

Lutz, et al. (2015)

Chronic boutonniere:

• Serial cast until full extension

• Progress to orthosis for 6-8 weeks

• DIP AROM important

Lutz et al. (2015)

SAM: Short Arc Motion

• Week 1: flexion to 30°

• Week 2: flexion to 45°

• If good extensors no SAM needed during AROM

• DIP blocking AROM

• 5-10 reps 5x daily

Photos from Ascension web site

Evans, R. B. (1995)

Relative motion flexion orthosis for

long finger boutonniere deformity

Lalonde, D. (2015). Managing Boutonniere and swan-neck deformities. BMC Proceedings,

9 (Suppl 3)

Merritt, W. H. (2014). Relative Motion Splint: Active Motion After Extensor Tendon Injury

and Repair. The Journal of Hand Surgery, 39(6), 1187–1194.

When do you begin the relative movement orthosis

(Lalonde, 2013)?

• Serial cast until full PIP extension and DIP full active flexion

• Then begin 8 weeks of full PIP extension orthosis

• After 8 weeks begin relative motion flexion for an additional 4-8 weeks with night PIP extension orthosis.

How much more MP

flexion than the other

digits?

• Originally 20-30◦

• Some studies report

15-20 ◦

Hirth, M. J., Howell, J. W., O'Brien, L. (2016)

Relative motion orthoses in the management of various

hand conditions: A scoping review.

Journal of Hand Therapy, 29(4):405-432. doi:

10.1016/j.jht.2016.07.001. Epub 2016 Oct 25.

Lateral Alignment Issues

• Conservative • Surgical

References

• Cole T, Robinson L, Romero L, O’Brien L. (2017). Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: a systematic review. Journal of Hand Therapy. Available online 29 December 2017 https://ac-els-cdn-com.ezproxy.gvsu.edu/S0894113017302818/1-s2.0-S0894113017302818-main.pdf?_tid=3b8da7f0-bff0-435f-a9d0-b3bea75dad75&acdnat=1548441461_fd109331116f3d6b3ce86f6060dff803

• Chinchalkar, S. J. & Gan, B. S. (2003). Management of proximal interphalangeal joint fractures and dislocations. Journal of Hand Therapy, 16, 2, 117-128.

• Doyle, J. R. (1993). Extensor tendons-acute injuries. In Green D. P. (Ed). Operative Hand Surgery. (3rd ed., pp. 1924-1954). New York: Churchill-Livingstone.

• Erçöçen A. R., Yenidünya, M.O., Yilmaz, S., Ozbek, M.R. (1997) Dynamic swan neck deformity in a patient with Ehlers-Danlos syndrome. Journal of Hand Surgery Br., 22:128–30.

• Handoll, H. H., Vaghela, M. V. (2014). Interventions for treating mallet finger injuries. Cochrane Database Systematic Reviews, 3:CD004574.

• Hirth, M. J., Howell, J. W., O'Brien, L. (2016) Relative motion orthoses in the management of various hand conditions: A scoping review. Journal of Hand Therapy, 29(4):405-432. doi: 10.1016/j.jht.2016.07.001. Epub 2016 Oct 25.

• Lalonde, D. (2015). Managing Boutonniere and swan-neck deformities. BMC Proceedings, 9 (Suppl 3)

• Lawrence, A. (2005). Benign hypermobility syndrome. Journal of Indian Rheumatology Association,13:150–5.

• Lin J.S., Samora, J.B. (2018). Surgical and nonsurgical management of mallet finger: a systematic review. Journal of Hand Surg Am.43(2):146e163.

• Merritt, W. H. (2014). Relative Motion Splint: Active Motion After Extensor Tendon Injury and Repair. The Journal of Hand Surgery, 39(6), 1187–1194.

• O’Brien, L. J., & Bailey, M. J. (2011). Single blind, prospective, randomized controlled trial comparing dorsal aluminum and custom thermoplastic splints to Stack splint for acute mallet finger. Archives of Physical Medicine and Rehabilitation, 92(2), 191-198. https://doi.org/10.1016/j.apmr.2010.10.035.

• Pike, J., Mulpuri, K., Metzler, M., Ng, G., Wells, N., Goetz, T. (2010). Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. The Journal of Hand Surgery, 35(4), 580-8. https://doi.org/10.1016/j.jhsa.2010.01.005.

• Porter, B. J., Brittain, A. (2012) Splinting and hand exercise for three common hand deformities in rheumatoid arthritis: a clinical perspective. Current Opinion in Rheumatology, 24(2):215-21. doi: 10.1097/BOR.0b013e3283503361.

• Spicka C, Macleod C, Adams J, Metcalf C. (2009) Effect of silver ring splint on hand dexterity and grip strength in patients with rheumatoid arthritis: an observational pilot study. Hand Therapy, 14: (2): 53-7.

• Stark, H. H., Boyles, J. H., & Wilson, J. N. (1962). Journal of Bone and Joint Surgery, 44, 1061-1068.

• Tar Schegget M; Knipping A.(2000) A study comparing use and effects of custom-made versus prefabricated splints for swan neck deformity in patients with rheumatoid arthritis. British Journal of Hand Therapy; 5(4): 101-7.

• Willoughby, J. A., Norris, S. H., & Fergusen, G. D. (1988). Extensor tendon imbalance: Mallet finger, swan-neck deformity, and boutonniere deformity. In S. L. Burke, J. P. Higgins, M. A. McClinton, R. J. Saunders, & L Valdata (Eds.), Hand and upper extremity rehabilitation: A practical guide (pp. 293-326). St. Louis: Elsevier.

• Witherow, E., Peiris, C. (2015). Custom-made finger orthoses have fewer skin complications than prefabricated finger orthoses in management of mallet injury: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 96(10), 1913-23. https://doi.org/10.1016/j.apmr.2015.04.026

• Valdes K, Naughton N, Algar L. (2015). Conservative treatment of mallet finger: a systematic review. Journal of Hand Therapy, 28(3):237e245.

• Zijlstra, T. R., HeijnsdijkRouwenhorst, L., & Rasker, J. J. (2004). Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis &Rheumatism, 51(6), 947-951.

RALEIGH J. FINKELSTEIN HALL

Thank you!