SOFT TISSUE MALLET INJURY: DELAYED TREATMENT 1805

Evidence-Based

Medicine

However, consideration should be made of the ap-propriateness of studying this clinical entity on such alarge scale. The rarity of the diagnosis, the lack ofsubstantial functional impairment even in cases with aresidual DIP joint extensor lag associated with a mildswan-neck deformity, and the lack of significant vari-ability in the results of current single cohort studiesquestion the value of pursuing a largely aesthetic con-cern at the cost of significant financial and logisticalresources.

OUR CURRENT CONCEPTS FOR THIS PATIENTFor patients who present more than a month after a softtissue mallet injury, we prefer to start with continuousextension splinting of the DIP joint for 6 weeks. If anextension lag persists after 6 weeks, we continue splint-ing for another 4 to 6 weeks.

Given that residual DIP joint extensor lag is largelyan aesthetic rather than a functional concern, we favormultiple attempts at nonoperative treatment with exten-sion splints, even for recurrences. By and large, after weattempt splinting for 12 to 14 weeks, most patients donot proceed to surgical intervention because the residualextensor lag is acceptable. Furthermore, surgical inter-vention in our hands for delayed mallet deformitiesdoes not reliably address aesthetic concerns. In the veryrare instance in which a patient presents with a delayed

JOURNAL CME QUESTIONS

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where we believe there may be some impact on func-tion, we would offer a Fowler (central slip) tenotomywithout a trial of 3 months of splinting.

REFERENCES

1. Patel MR, Desai SS, Bassini-Lipson L. Conservative management ofchronic mallet finger. J Hand Surg Am. 1986;l l(4):570–573

2. Garberman SF, Diao E, Peimer CA. Mallet finger: results of earlyversus delayed closed treatment. J Hand Surg Am. 1994;19(5):850–852.

3. Iselin F, Levame J, Godoy J. Simplified technique for treating malletfinger: tendermodesis. J Hand Surg. 1977;2(2):118–121.

4. Kon M, Bloem JJ. Treatment of mallet fingers by tenodermodesis.Hand. 1982;14(2):174–176.

5. Bowers WH, Hurst LC. Chronic mallet finger: the use of Fowler’scentral slip release. J Hand Surg Am. 1978;3(4):373–376.

6. Grundberg AB, Reagan DS. Central slip tenotomy for chronic malletfinger deformity. J Hand Surg Am. 1987;12(4):545–547.

7. Houpt P, Dijkstra R, Storm van Leeuwen JB. Fowler’s tenotomy formallet deformity. J Hand Surg Br. 1993;18(4):499–500.

8. Lucas GL. Fowler central slip tenotomy for old mallet deformity.Plast Reconstr Surg. 1987;80(1):92–94.

9. Kleinman WB, Petersen DP. Oblique retinacular ligament recon-struction for chronic mallet finger deformity. J Hand Surg Am.1984;9(3):399–404.

10. Gu YP, Zhu SM. A new technique for repair of acute or chronicextensor tendon injuries in zone 1. J Bone Joint Surg Br. 2012;94(5):668–670.

11. Lind J, Hansen B. Abbrevatio: a new operation for chonic malletfinger. J Hand Surg Br. 1989;14(3):347–349.

12. Ulker E, Cengiz A, Ozge E, et al. Repair of chronic mallet fingerdeformity using Mitek micro arc bone anchor. Ann Plast Surg.

mallet finger and concomitant swan-neck deformity 2005;54(4):393–396.

Soft Tissue Mallet Finger Injuries WithDelayed Treatment

What is the most preferred initial treatmentoption for a symptomatic patient with chronicsoft tissue mallet finger injury?

a. Palmaris longus tendon graft

b. Suture anchor re-attachment of the terminal ex-tensor tendon

c. Spiral oblique retinacular ligament reconstruction

d. Observation with or without stretching exercisesfor 4 weeks

Fowler central slip tenotomy procedure isindicated for which of the following?

a. Any mallet finger deformity of 10°

b. Acute mallet finger deformity of 30°

c. Acute bony mallet finger deformity of 40°

d. Chronic mallet finger and concomitant swan-neck deformity

e. Chronic soft tissue mallet finger and attenuatedcentral tendon

e. Extension splinting for 6 weeks

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