Mallet Finger – Causes, Symptoms, and Treatments

So you injured your finger from playing basketball, and now you think you have a mallet finger? Well, here are some facts, tips and all the other things you need to know about it—presented in a simple, comprehensive manner, of course.

First of all, the mallet finger is not the same as a jammed finger. Mallet finger involves the distal interphalangeal joint (DIP) while the jammed finger occurs more commonly and affects the proximal interphalangeal (PIP) joint.

DIP and PIP joints are just fancy words for the farthest and middle joints in your finger. Each finger has 3 parts called phalanges and interphalangeal only means between these parts.

What is A mallet finger?

The mallet finger is so-called because it resembles a mallet or a hammer. Your muscles can control bones through connections like tendons. But in this case, no matter how much you try to lift the bony end of your finger, it does not rise and simply droops.

This is because the tendon holding the most distal portion of your finger is injured or torn; this tendon is called extensor digitorum. This tendon at the end of your finger is quite thin (only about 1 mm thick) and is very prone to injuries during sports like baseball or basketball.

If treatment is not sought promptly, the PIP joint will also be involved. Through the continuous pull of the muscles over its intact tendon, it will hyper-extend and look as if it’s curved upward. All the while, your DIP joint remains drooped downward and in the end, your finger would have a swan neck deformity.

If you have a mallet finger and its appearance does not bother you anyway, you should still have it checked by a physician lest you want it to proceed to a swan neck deformity. If this happens, the functionality of your finger will then be compromised.

Mallet Finger Causes

The most common cause of mallet finger a physician hears about is sports, although this can also happen at home.  Any sports, whether softball, basketball or volleyball—as long as the hand is used—is capable of causing a finger accident.

A mallet finger happens when a person has his finger extended and gets it struck by a ball or any hard object.

The speed at which an object hits your finger determines the degree of damage it receives rather than the weight of the object alone. In this event, the tendon may partly tear or rupture completely and bones may also get fractured.

Signs and symptoms

A mallet finger is an injury to the tip of your finger. Usually, someone who sustains a mallet finger injury describes ‘jamming’ their finger. After the injury has occurred, the individual may notices that they are unable to fully straighten the tip of the finger.

Symptoms of a mallet finger: the last joint of the finger will be bent down, and while the joint can be straightened with assistance, you will be unable to fully straighten the tip of the finger on your own.

Pain associated with a mallet finger can be significant at the time of the injury but is usually minimal within a short time. Some people with a mallet finger are tender at the site of the injury, just behind the base of the fingernail.

Due to minimal pain, many mallet fingers go undiagnosed for weeks or longer, because people are unaware of the significance of their injury.

Upon injuring your finger, it will get inflamed. The 4 signs of inflammation you will notice are rubor (redness), dolor (pain), calor (heat) and tumor (swelling). There is a fifth sign which you won’t notice until later and that is functio laesa (loss of function).

The most obvious indication that this is a mallet finger is if the fingertip droops; however the form of a mallet will not show until later after days or weeks.

Therefore the initial swollen appearance may be mistaken for a simple sprain and patients should take caution in this assumption.  Your suspicion of a mallet finger or a more serious injury should increase if you see blood under your nails.

Mallet Finger Treatments

The first thing you have to remember with a suspected finger injury or any other sports-related injuries for that matter is the R.I.C.E. protocol. It simply means (Rest, Ice, Compress and Elevate). This is the first aid for mallet finger:

• Rest: do not try to use, flex or extend your finger. Keep it straight. Avoid making movements especially if there are broken bone fragments inside the joint.
• Ice: Put ice around the finger to minimize swelling.
• Compress: apply pressure by using a bandage; this might also relieve some pain.
• Elevate: Keep your hand elevated or at least at the same level as your chest. You don’t want the blood to pool in your injured finger and aggravate the inflammation.
• The next thing to do is consult a physician—the earlier the better. If an initial assessment (for example, x-ray) shows that you only have a mild injury, then most probably you will only need to get a splint. In case you can’t immediately see your doctor, you can take oral painkillers (ibuprofen) for the pain while keeping your finger in a temporary splint using tongue depressors and tape.

Mallet Finger Surgery

Surgery is never the first option for mallet fingers. Aside from an ugly scar on your finger, the end result could also include stiffness and limited range of motion due to fibrosis in the healing process.

Surgery is only done if there is a large fracture, bone fragments or misalignment that cannot be addressed through non-surgical techniques. Consult an orthopedic surgeon for a good plan of action. Some surgical procedures doctors use are briefly discussed below.

Open reduction and internal fixation

Under anesthesia, a Y-shaped flap (other shapes of flap may be preferred) will be performed on your finger to expose the joint below. The joint capsule is then cut to visualize the fracture and then a bone reduction clamp is used to stabilize and straighten it; this is the reduction part.

Next, two small screws will be drilled down parallel to each other which will attach the fractured fragment to the rest of the bone. This use of screws to hold bone is the internal fixation part. Finally, tendon and skin are sutured.

Modified Extension block K-wire

In simple words, a total of 3 wires will be inserted in your finger to hold it in place; this is done under anesthesia, of course. The farthest third of your finger will be flexed followed by insertion of the first 2 wires from above one at a time, with a distance of about 2-3 mm between them.

Next, your finger will be slightly straightened to insert the third wire from below. This last wire goes right between the first two. This procedure takes a longer time (6 weeks plus another 2 weeks in a splint) than a simple splint but allows a better range of motion of the DIP joint.

Mallet Finger Splint

A properly placed splint will keep your fingers from bending; some even have holes to provide ventilation.

Although keeping your finger slightly hyper-extended or bent upward in a splint will facilitate the approximation of your tendon for proper healing; there are also some advantages to keeping it flexed.

Flexing the knuckle and finger joints (15-20°) will stretch the ligaments and tendons to provide allowance when the wound contracts; this will avoid stiffness in movements later on.

Depending on the involved tissue, the duration you have to wear your splint varies.

If your injury involves the tendon, you will need 6-8 weeks of splinting, if it involves bone fracture, you will need a shorter 4-5 weeks. You have options when it comes to splints: regarding the positioning: dorsal vs. volar and regarding the material: plastic, metal, or plaster.

Here are some pointers for wearing splints:

• Never take off the splint unless you absolutely have to.
• Never bend your finger! The tissues could misalign or separate again.
• Avoid getting the splint wet.

Your doctor will probably also recommend you to see a hand therapist for some finger exercises that will keep your fingers from having excessive tissue adhesion during healing.

However, some patients, depending on the extent of the injury, will still not regain the full range of motion of the fingertip. This is what typically happens when the injured tissues start to heal and produce new cells, collagen and the rest of the matrix for repair.

In pediatric cases, the healing process should be carefully monitored especially if the cartilage is involved; because the young bone is still growing, measures should be taken to ensure that no stunting or scar is formed.

FAQ

What causes a mallet finger?

The mechanism of the finger which straightens the end joint has been damaged. This can happen when the tip of the finger is pushed down while the person is trying to straighten the finger.

The tendon which pulls on the end been to straighten the finger pulls one way and the force on the end of the fingertip pulls the other way, and something comes apart in between.

A lot of times, the tendon tears away from its attachment to the bone. In some cases, the tendon comes off with a piece of bone attached.

In the worst case, the tendon comes off with a large piece of bone, which can make the rest of the joint slide out of alignment. Fortunately, this is not happening often.

Don’t ignore a mallet finger

Some people ignore a bent finger, assuming that it will straighten out on its own, but this is very unlikely to happen. The longer the finger stays bent, the harder it will be to fix it.

Can a therapist help?

A mallet finger can be treated by a therapist. The therapist can provide a comfortable splint to straighten the mallet finger. You can also do exercises later on if stiffness is a problem.

A good splint for your mallet finger is important because the proper treatment involves wearing the splint continuously for a long period of time.

How to fix the mallet finger? What can a doctor do?

• A doctor can give you the confirmation it is indeed a mallet finger.
• Prescribe hand therapy to go to a therapist and prescribe a custom prescription splint.
• Sometimes, a doctor can perform surgery to reconstruct the attachment of the tendon. This type of surgery is usually not necessary unless the injury is from a cut on the back of the finger.
• If a splint cannot get the mallet finger back into position, it may be helpful for the surgeon to place a temporary metal pin in the mallet finger to hold the joint straight and act as an ‘internal’ splint.
• After any surgery or therapy, splinting may be needed for several months more.

Is treatment successful?

If you get surgery for a mallet finger, it might seem like a simple injury. But a cosmetically perfect correction is not likely with any form of treatment. However, with proper therapy and effort on the part of the patient, this problem can usually be improved to a tolerable level.

The end joint of the finger may not fully straighten ever again, but it will work well enough to be used for normal activities.

If the mallet finger is a cause due to a cut on the back of the finger, many hand surgeons believe that the final outcome and complication rate are at least as good with splinting alone compared to surgical repair.

This may change as there are coming new techniques nowadays which improve results of mallet finger surgery.

It is reasonable to consider surgery if the mallet finger remains unacceptably bent after a full trial of splinting or if splinting is not even possible.

For example; if a skin reaction develops beneath the splint. Surgery is only considered if the outcome of surgery is expected to be better than the outcome of treatment without surgery.

What happens if you don’t treat a mallet finger?

Without treatment, the appearance and ability to straighten the end joint of the finger will not improve. Additionally, if the injury is less than one month old, the problem may be worsened by using the mallet finger without a protective splint of some sort.

If you are walking around with a mallet finger for more than three months, it is unlikely that it will get better or worse on its own.