1994 Jan-Mar;7(1):21–24. The finger should be kept dry and examined regularly for. Mallet finger is an injury to the tip of the finger when something hard, like a baseball, jams it. Aligning the PIP joint and preventing hyperextension should help restore DIP extension. This can be assessed using the Elson Test. In cases of tendon laceration, the terminal tendon is usually repaired surgically together (with pinning the DIP joint straight to protect the repair). This produces disruption or stretching of the extensor mechanism over the DIP joint. An inability to actively extend the PIPJ completely. Splinting is used for approximately 6 to 8 weeks to allow tendon healing. Materials and Methods: Thirty patients with spastic CP were operated upon due to flexion deformity of the wrist and fingers and were included in this study. Hand Clin. of the joint. Central slip extensor tendon injury (may cause a boutonniére deformity over time), Tender at dorsal aspect of the PIP joint (middle phalanx). Wang QC, Pain and tenderness over the dorsum of the PIPJ 2. Radiographs are obtained to define any bony injury, especially an. Typically, a custom-made splint is used to hold the MCP joint of the involved finger at 10-15° of flexion, leaving the PIP and distal interphalangeal (DIP) joints free. DeLone FX Jr, Treatment options can then be based on the classification of the deformity; options consist of corrective splinting, injections, synovectomy, terminal tenotomy, extensor reconstruction, or … In: DeLee JC, Drez D Jr, Miller MD, eds. Lairmore JR, Immediate, unlimited access to all AFP content. Hankin FM, The deformity is located at the proximal interphalangeal joint and also usually involves the fifth finger (Fig. Splint the PIP joint in full extension for six weeks. It is important to establish what forces were applied to the hand during the injury and the direction of these forces, as well as any special features of the injury. The mechanism of injury gives important clues about the structures involved and potential complications. Symptom. Almost all anatomical structures of the hand have been held responsible for non-traumatic, non-paralytic flexion deformity … The injury causes forced extension of the DIP joint during active flexion. Patients with PIP joint injuries may continue to participate in athletic events during the splinting period, although some sports are difficult to play with a fully-extended PIP joint. Surgical release of the first annular pulley may be offered as a treatment option to restore thumb IP joint movement if there is a fixed flexion deformity beyond the age of 12 months or if conservative management fails. Splinting duration is the same as with mallet finger. 21. Macdonald MR, If the ring finger is involved, it should be secured to the fifth digit, because the fifth digit is naturally extended and easily injured if exposed. Improper diagnosis and treatment of finger injuries can cause deformity and dysfunction over time. Sportrelated fractures and dislocations in the hand. Any subluxation requires open reduction and internal fixation. Neurovascular and active flexion/extension testing will reveal clues to tendon and ligament injuries as well as subtle rotational abnormalities. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Peel SM. 5(March 1, 2006) The splint creates pressure to straighten and immobilize the finger. 1. It attaches to the base of the distal phalanx and flexes the DIP.4 Figure 1 illustrates the basic anatomy of the finger, including joints, ligaments, and tendons. Fixed flexion deformity (FFD), also known as flexion contracture, is a common complication following traumatic injury to the PIPJ (Hunter, Laverty, Pollock, & Birch, 1999). In the remaining patients accurate measurements could not be calculated because of a lack of preoperative range of motion documentation or inability to examine patients. The central tendon slip and lateral bands do not have to be powerful. The PIP joint usually is involved in collateral ligament injuries, which are commonly classified as “jammed fingers.”. Sokolove PE. Persistent DIP flexion deformity can lead to swan-neck deformity (pathologic flexion of the DIP joint and hyperextension of the PIP joint), terminal joint extensor lag, and degenerative joint disease (24–26). J Hand Surg Am 1994; 19:850. PIP = proximal interphalangeal; MCP = metacarpophalangeal; DIP = distal interphalangeal; FDP = flexor digitorum profundus. Brown DE, Whalen MJ. Am Fam Physician. 19. Choose a single article, issue, or full-access subscription. Akelman E. 7. We thus modified Zancolli's classification and developed a classification system and treatment protocol. Splinting and taping are effective treatments for tendon and ligament injuries. An awareness of this anatomical division during botulinum toxin injection in the flexor digitorum superficialis muscles is important because if the neuromuscular blockade involves the whole muscle, although the flexion deformity improves, the resulting weakness of the index flexor causes weakness of pinch grip and increased functional disability. Meko CJ. In: Marx JA, Hockberger RS, Walls RM, Adams J, eds. Some splints also incorporate the PIP joint, keeping it flexed. DeLee and Drez’s orthopaedic sports medicine: principles and practice. If a contracture is less than 30 degrees, it may not interfere with normal functioning. These essentially reverse the swan-neck deformity. : Mosby, 2002. 1. Some surgical procedures can be indicated by the hand specialist when the … Accessed online November 2, 2005, at: http://acr.org/s_acr/bin.asp?CID=1206&DID=11792&DOC=FILE.PDF. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For complicated mallet finger injuries operative treatment has also been recommended. This disruption of the ligament and tendon will cause the lateral bands to displace volarly. Vaghela MV. Allowing the skin to “breathe” for 10 to 20 minutes between splint changes minimizes the risk of maceration. If active extension is present, splinting can be limited to when the patient is sleeping and during athletic events for another six weeks. J Hand Surg Am 1994; 19:850. The collateral ligaments should be tested as with collateral ligament injuries. Nonsurgical Options Nonsurgical treatment is usually preferred, and may include: Splints: A splint will be applied to the finger at the middle joint to straighten it. 15. Treatment decisions are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface. Brzezienski MA, Schneider LH. 1992;11:77–99. Philadelphia, Pa.: Lippincott-Raven, 1996. This is part I of a two-part article on finger injuries. Bach AW. In cases of tendon laceration, the terminal tendon is usually repaired surgically together (with pinning the DIP joint straight to protect the repair). Previous: Cyclic vs. The physical examination demonstrates the drooped posture of the DIP joint with an inability to completely extend the joint. Flexion deformity. Conservative treatment. 4. Clinical procedures in emergency medicine. Central … 18. 2001;26:32–3. The flexor digitorum superficialis tendon attaches to the base of the middle phalanx and flexes the PIP joint. Management of proximal interphalangeal joint injuries. Splint finger and refer to orthopedic or hand surgeon. A patient with jersey finger may present with pain and swelling at the volar aspect of the DIP joint and the finger may be extended with the hand at rest. Sokolove PE. In isolated middle finger deformity the average MCP joint flexion deformity was 55° before surgery and 10° after surgery with less than 10° of flexion loss. He completed a family practice residency at Dewitt Army Community Hospital, Fort Belvoir, Va.... CHRISTIAN J. MEKO, CAPT, MC, USA, is staff family physician at Womack Army Medical Center, Fort Bragg, N.C. For complicated mallet finger injuries operative treatment has also been recommended. Its delicate balance allows the integration of intrinsic and extrinsic muscle function to coordinate fine digital motion. The physician should evaluate active flexion and extension by asking the patient to open and close his or her fist. Mallet finger: results of early versus delayed closed treatment. Wang QC, Rettig AC. Continuous or Extended- Cycle Combined Contraceptives, Next: Acute Finger Injuries: Part II. Injury to the extensor tendon at the DIP joint, also known as mallet finger (Figure 2), is the most common closed tendon injury of the finger. When the fifth finger is referred to, it will be called clinodactyly 5. Patients will present with the following: 1. Get Permissions, Access the latest issue of American Family Physician. Former PT Winner Regional Health, South Dakota, Former HOD Physiotherapy & Fitness center @ NIMT Hospital, Greater Noida. DIP joint should be isolated during the examination. The consequences of not splinting are a chronic mallet finger type flexion deformity with osteophyte formation and degeneration of the DIP surface. Athletic injuries of the adult hand. Fracture management for primary care. Camptodactyly (1, 8, 26, 67, 70, 72) (Gr. Fractures, dislocations, and thumb injuries. Serious, often subtle, finger injuries. Philadelphia, Pa.: Saunders, 2003:1381–441. 2001;19:76–80. Closed mallet finger injuries are managed in a strict extension or hyperextension immobilisation … 1990;6:429–53. J Bone Joint Surg Br 1997; 79:544. Two almost identical elderly women are described who presented with gradually progressive painless involuntary flexion of the ring and middle fingers over 12 months, leading eventually to contractures. Complications and prognosis of treatment of mallet finger. The aim of treating a mallet finger deformity is to rebuild the exten-sor tendon insertion and restore extensor ten-don length to achieve balance of distal inter-phalangeal joint flexion. Hand of Benediction: Patient information: See related handout on mallet finger, written by the authors of this article. 14. Office sports medicine. Anatomy of the finger. Increasing the extension of a dorsal aluminum splint weekly will progressively increase range of motion.22 In less severe injuries, the injured joint should be buddy taped. Five-year follow-up of conservative treatment. are variable. Mallet finger. Akelman E. If the joints are stable and no large fracture fragments are present, the injury can be treated with buddy taping (i.e., taping the injured finger, above and below the joint, to an adjacent finger) (Figure 7). In: Mellion MB, ed. 4th ed. (B) Velcro wrap. Clin Sports Med. If left untreated, a chronic mallet finger type deformity develops. The flexion deformity … (B) The superficialis test is performed by holding the unaffected fingers in extension and asking the patient to flex the injured finger. Rosen’s Emergency medicine: concepts and clinical practice. Complications and prognosis of treatment of mallet finger. Non Surgical May have continuous splinting for approximately six weeks followed by six weeks of nighttime splinting. For uncomplicated mallet finger treatment involves splinting of the DIP (distal interphalangeal) joint in slight hyperextension for a period of upto 8 weeks, with regular monitoring. Postoperative management: Dorsal plaster of Paris with extended fingers and compressive dressing in the palm for 2 days, occupational/physical therapy, static … These injuries should be assessed accurately and closely monitored. Figure 5 illustrates these techniques. As with mallet finger, extension of the PIP joint must be maintained continuously. Finger joint injuries in active patients. the middle knuckle bending backward (hyperextends) and the fingertip bending down towards the palm, (A) Self-adhesive wrap. Am J Emerg Med. Mallet deformity in sport. Extensor tendon injuries at the distal interphalangeal joint. Copyright © 2020 American Academy of Family Physicians. Antosia RE, Lyn E. The hand. 2nd ed. Treatment of Boutonniere Deformity… Continuous or Extended- Cycle Combined Contraceptives, Acute Finger Injuries: Part II. Hand, wrist, elbow, and forearm injures. Proximal interphalangeal joint (PIPJ) flexion contracture is a challenging and often frustrating problem. There is slight flexion at this joint, which is where the term "mallet" comes from - the finger position resembles a mallet (for example, a piano key mallet). ACR appropriateness criteria. afpserv@aafp.org for copyright questions and/or permission requests. The central tendon slip attaches to the epiphysis at the base of the middle phalanx . Acute finger injuries: part II. 4th ed. From a fully flexed position, with the Metacarpophalangeal Joint (MCPJ) in neutral, the patient tries to actively extend the PIP… The PIP joint should be splinted in full extension for six weeks if there is no avulsion or if the avulsion involves less than one third of the joint. Graham TJ, Mullen DJ. Address correspondence to Jeffrey C. Leggit, LTC, MC, USA, 107 Sawmill Rd., St. Robert, MO 65584 (e-mail: Leggit JC, To optimize treatment… Pes anserine bursitis (tendinitis) involves inflammation of the bursa at the insertion of the pes anserine tendons on the medial proximal tibia. sidered pathognomonic of thd buttonhole or boutonniere deformity of the finger. Ultrasonic assistance in the diagnosis of hand flexor tendon injuries. Mallet Finger. Conservative treatment is successful for up to three months, even with delayed presentation.11 Referral criteria include bony avulsions involving over 30 percent of the joint space or the inability to achieve full passive extension. 3 ): 244–248 version of this article all mallet finger type deformity develops pain tenderness... Healing and allow the terminal tendon to heal over several weeks as the intact lateral bands of hand... Under and splits the flexor digitorum superficialis tendon attaches to the tip of the joint. 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