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Stop! Hammer Time
A 54-year-old female presents to the emergency department with 3rd and 4th finger pain on the right after “jamming” them a week ago. She was reaching to tap someone on the shoulder and they backed into her hand forcing her fingers into flexion. She has swelling and pain at the DIP joint of her 3rd and 4th digits on the right and cannot extend the digits at the DIP joint.
Stop! Hammer Time
Author: R. Conner Dixon, MD
Peer-Reviewer: Katie Dolbec, MD, CAQ-SM
Final Editor: Alex Tomesch, MD, CAQ-SM
A 54-year-old female presents to the emergency department with 3rd and 4th finger pain on the right after “jamming” them a week ago. She was reaching to tap someone on the shoulder and they backed into her hand forcing her fingers into flexion. She has swelling and pain at the DIP joint of her 3rd and 4th digits on the right and cannot extend the digits at the DIP joint.
Image 1: Author’s own images
What are the key exam findings?
The distal phalanx will typically be flexed with the patient unable to actively extend at the distal interphalangeal (DIP) joint. There is typically a normal appearance and function of the proximal interphalangeal (PIP) and meatcarpo-phalangeal (MCP) joints in the weeks to months after the initial injury.
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Pearl: It is important to isolate each interphalangeal joint when testing extension and flexion
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Pearl: Mallet finger should not be confused with other common traumatic finger deformities such as a boutonniere deformity (central slip deformity) or a swan-neck deformity (untreated mallet finger) [2].
Image 2: Courtesy of Core EM
What is your management in the ED? Do I need to consult Orthopedics?
The affected digit should be splinted in extension at the DIP, ideally with a stack splint or figure of 8 splint, for 6-8 weeks [1]. Orthopedics does not need to be consulted in the ED but urgent follow-up should be arranged, especially if there are bony avulsions, to evaluate the need for surgical repair.
- Pearl: Management is typically non-operative with the DIP splinted in extension AT ALL TIMES FOR 6-8 WEEKS. If the finger is allowed to flex at the DIP joint even briefly, the clock is reset and an additional 6-8 weeks of extension will be required [3].
- Pearl: Relative indications for surgical repair include an avulsion fracture involving >30% articular surface or volar subluxation of the distal phalanx [3].
- Pearl: If a mallet finger isn’t treated appropriately, it is likely to develop into a swan-neck deformity. Due to progressive increased extension tone across the PIP and migration of the extensor complex proximally, extension develops at the PIP and the DIP remains flexed, see image 3 [3].
Image 3: Courtesy of Don’t Forget the Bubbles
References
[1] StatPearls. Mallet Finger. StatPearls. https://www.statpearls.com/
[2] McDonald L. Finger injuries. Core EM. https://coreem.net/core/
[3] Lamaris GA, Matthew MK. The Diagnosis and Management of Mallet Finger Injuries. Hand (N Y). 2017;12(3):223-228. doi:10.1177/1558944716642763
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