Document 6476344

THE
RESULTS
OF
TREATMENT
W. A. T.
Senior
Mallet
finger
is the
attachment
to the
caused
by avulsion
and
the
the power
proximal
mechanism
The
EDINBURGH,
Registrar,
deformity
base of the
of a small
Royal
caused
terminal
triangular
of active
extension
interphalangeal
joint
of this joint.
method
of treatment
seen within
hyperextension
impression
ROBB,
OF
by
of Edinburgh
a tear
of
the
Sometimes
of bone.
extensor
expansion
there
is an
The terminal
from
associated
phalanx
its
fracture
is flexed
is lost, and there
may be a secondary
hyperextension
of
due to the exertion
of the full power
of the extensor
generally
recommended
for
a mallet
finger,
a few days
of injury,
is immobilisation
by a plaster
of the distal joint and flexion
of the proximal
joint
created
is that the immediate
results
of this treatment
Watson-Jones
FINGER
SCOTLAND
Infirmary
phalanx.
fragment
MALLET
particularly
if it is
splint
in the position
of
for four to six weeks.
The
are good
(Smillie
1937,
1940).
The present
review
was carried
out to assess
the long-term
particular
to determine
whether
or not freedom
from disability
and
were achieved.
results
of treatment,
and
restoration
offull
movement
in
MATERIAL
Seventy-five
the
Royal
shortest
patients
Infirmary
time
that
with
mallet
finger
treated
in the
surgical
out-patient
department
of Edinburgh
during
the years
1952, 1953 and 1954 were
had elapsed
between
the injury
and the follow-up
examination
of
reviewed.
The
was one year.
ETIOLOGY
The
more
and
in
than
index
fingers
general
this
was
found
women.
The
ring
with
agreement
injuries
The
in the
and
cases,
other
fifth
little
and
reported
the
sixth
were
thumb
series
and accidents
alleged
common
and
fingers
in
only
and
in
one
especially
such
men
fifty
were
cases,
case.
1930, Smillie
(Mason
in the home,
cause-sports,
decades,
injured
These
1937,
middle
findings
Ratliff
during
bed-making,
as cricket-was
not
affected
the
are
1947).
accounted
encountered
series.
In thirty
time
incidence
in twenty-four
Industrial
most
cases.
for
in
highest
often
the
of the
patient
was
seventy-five
first
cases
there
METHOD
Sixty-nine
patients
extension
of
the
of those
cases,
four weeks.
too tight,
plaster
come
to hospital.
Two patients
radiological
by
showed
OF
evidence
of a fracture
at
the
immobilisation
joint
that
TREATMENT
and
in only
flexion
thirty
had
In the others
a change
of splint
too loose,
or had become
soft
off and
had
treated
interphalangeal
however,
for at least
had become
had
were
distal
was
seen.
had
not
no treatment
been
and
replaced,
four
plaster
of
the
in
the
position
proximal
a satisfactory
joint.
plaster
of
An
been
hyperanalysis
maintained
had been required
because
the plaster
through
getting
wet.
Sometimes
the
usually
had
in
because
operative
repair
were
recorded
the
patient
of the
had
ruptured
not
reported
tendon.
RESULTS
Subjective-Any
patient
546
was
complaints
specifically
asked
made
by
the
about
discomfort
patients
or
any
interference
THE
JOURNAL
and,
with
OF
in
particular,
normal
BONE
AND
each
activities.
JOINT
SURGERY
THE
One
patient
in the
tended
to knock
immobilisation
Five
was
of her
complained
striking
of
especially
improvement
Objective-The
great
joint
was
individual
variation.
with the
compared
or
patient
(Table
extension
was
was
months
from
expressed
as
a
distal
percentage
of
OF
Active
Full
perfect
anatomical
deformity
was
restriction
ofactive
still
immobilisation
time
than
reached.
injury.
This
was
.
.
interphalangeal
from
of symptomatic
this freedom
The usual
joint
was
from
course
found
to
movement
of the affected
side and any limitation
of
normal
range
for
that
individual
50 per
movement,
twenty-eight
hyperextension
had
after
stiff
for
been
removal
for
a few
660
6
85
2
30
per
at
least
than
a quarter
and
cent)
the
had
a full
those
weeks
had
reasons
which
the
been
and
specifically
in which
carried
out,
been
considered
recurred.
noted.
uninterrupted
and
above.
deformity
some
movement.
those
Indeed,
in
many
satisfactory
Over
the deformity
slowly
but steadily
decreased
until the final state
No further
improvement
was ever noted
after
six months
from
also proved
true for those
patients
who had unsatisfactory
splints
individuals
who had no treatment.
Early
treatment-There
was no difference
treatment
within
three
days of the injury
a severe
with
ofpassive
were
cases
total,
patients
range
described
had
mallet
of the
fifty-five
factors
between
the
then
Of
following
four
for
of a plaster
days
47
a tenth.
inefficient
cent
225
in less
(51
Per
16
cent
obtained
was
(71 CASES)
of cases
.
in approximately
that
stated
.
of the results
of treatment
the
was no significant
difference
in
thereafter
was
absence
fact that
of treatment.
of injury.
TREATMENT
Number
.
per cent
result
immobilisation
finger
movement
present
In the analysis
!mmobilisation-There
patients
terminal
pain
I
AFTER
per cent
50-75
Less
MOVEMENT
range
75-100
affected
the
I).
RANGE
which
of
constant
the
the
constantly
by uninterrupted
region
severe
the complete
considerable
as she
treated
the
reason
active
and passive
joint
of the opposite
TABLE
A
been
had
elicited
the end
the time
caused
inasmuch
had
One
questioning
sequel
to
at a normal
power
in
weather.
of examination
For this
corresponding
of
discomfort
cold
several
lack
She
547
FINGER
activities
on things.”
six weeks.
occasional
of movement
MALLET
household
However,
immediate
over
range
flexion
and
during
in all but the above.
was not generally
an
show
deformity
ordinary
the joint.
finding
at the time
in
a slow
OF
persistent
course
joint,
The
TREATMENT
“
patients
osteoarthritis
OF
her finger and
it caught
of the finger in plaster
for
interphalangeal
disability
trouble
that
stated
inconvenience
RESULTS
the
a variable
of recovery
the time of
and for the
two
been delayed
Fracture-The
of
persistent
five
patients
for up to three weeks.
presence
of an associated
deformity,
but did increase
who
Operation-Of
complained
there was
distal
VOL.
complained
the
and
of discomfort
patients
who
NO.
3,
joint.
AUGUST
1959
ultimate
those
outcome
in whom
between
the
fracture
in thirty
cases
the liability
to subjective
had
had
of discomfort.
Only
one had
an average
restriction
of extension
interphalangeal
41 B,
four
in the
sustained
operative
start
did
patients
of the
not affect
complaints.
who
treatment
had
had
the incidence
Four
of the
a fracture.
repair
a perfect
anatomical
by 20 degrees
and
of
the
result:
of flexion
ruptured
tendon
one
in the other
by 10 degrees
three
at the
548
W.
Complications
of treatment-Ten
A. T. ROBB
patients
had
pressure
sores,
eight
of which
were
over
the
the distal
interphalangeal
joint,
and the scarring
associated
with healing
had
caused
some
limitation
of flexion.
Since
the completion
of this follow-up,
one patient
has
been
seen
in whom too tight a plaster
had caused
gangrene
ofthe
terminal
phalanx,
necessitating
dorsal
aspect
of
partial
amputation
of the
finger.
DISCUSSION
The
flexion
extensor
principle
of treatment
of the proximal
joint
fixes the
aponeurosis
to be approximated
Many
types
of splint
method
is the
I) Application-The
(1947),
(1947)
for
immobilisation
mallet
may
observations
of
the
recurs.
Duncan
extended
joint
half
of
some
the
the
and
with
flexion
other
writers
that
patients
Mason
the
noted
fingers
a Kirschner
recommended
is based
the
on the
of the
plaster
results
conservative
maintain
of the
efficient
was
on
invariably
a fully
in approximately
have
position
ruptured
of
deformity
internal
are not always
satisfactory.
The
range
of movement
is uncommon.
of
the
removal
the
treatment
desired
had
period
it be
confirms
cases
advised
the
repair
an
thus
recurred
(1952)
use:
Howie
to have
that
there
early
operative
shows
in many
deformity
of
its
immobilisation
and
It
that
Pratt
popular
with
(1944),
of plaster
1952).
but
most
considered
considerable
the flexion
to
the
that
of the
of plaster
during
the
joint-even
though
difficulties
Pratt
fact
bands
of fitting
were
hours
wire
but
difficulty
patients
are
operation.
early
position,
Any change
interphalangeal
joint
removal
poor
The results
of operative
repair
good
but the restoration
of a full
often
given.
distal
1950,
on
by
the
be satisfactory
forty-eight
The
this
indicate
half
middle
may
immediate
finger
two problems
associated
by Smillie
(1937),
Bunnell
of treatment.
the mechanical
the
out
are
than
already
of the
that
within
carry
(1930)
less
(Rosenzweig
treated.
to
of
of
maintain
(1956)
series
results
(1948)
but
to
There
described
Watson-Jones
the principle
indicates
that
immediate
surgeons
joints
devised
the reasons
allow
flexion
upsets
review
finger
plaster
been
this
plaster
momentary-and
The present
the
and
2) Maintenance-In
a satisfactory
a
have
of a mallet
middle
slip and allows
the two lateral
to the site of their distal
attachment.
application
of a plaster.
different
techniques
Williams
plaster.
of
by hyperextension
caused
fixation
for
six
of
weeks,
extensor
expansion.
cosmetic
In fact,
effect may
movement
be
is
less than after conservative
treatment
: in particular,
be restricted
by scarring
on the dorsal
aspect,
joint
flexion
of the distal
interphalangeal
as was noted
in three
of our four
(1950)
also considered
that
the results
may
patients
who
of operative
The
were
treated
repair
assessment
unnecessary.
by
operation.
of
the
late
Improvement
proceed,
incomplete
and,
although
extension,
with
of
that
the
Rosenzweig
in practically
Rosenzweig
“
left a lot to be desired.”
all cases
results
occurs
lengthening
subjective
(1950),
of mallet
in
this
gradually
series
as
of the tendon
end results
are
and
finger
suggests
healing
that
and
is responsible
good.
This
operative
of
repair
fibrous
that
a satisfactory
if no treatment
is given.
state
The
with adhesive
strapping
or a straight
spatula
splint
may be applied
the fingers
to relieve
the initial discomfort
associated
with the injury.
which
is easy to apply,
comfortable
for the patient
and devoid
of the
now being
used in this department.
of recovery
finger may
is
tissue
for a high
incidence
assessment
is in agreement
suggests
even
early
contraction
of
will occur
be strapped
to the palmar
aspect
This form of treatment,
of
risk
is
of pressure
sores,
CONCLUSIONS
I.
The
the
position
method
interphalangeal
of
of treatment
of a mallet
hyperextension
joint
is, on
of the
the
whole,
it may need to be changed
frequently,
2. In many cases the deformity
is still
but
gradual
improvement
from
finger
distal
deformity
by immobilisation
interphalangeal
unsatisfactory
it is
present
and
the contraction
joint
because
sometimes
after
and
the
in a plaster
flexion
splint
of the
is difficult
in
proximal
to apply,
by pressure
sores.
of adequate
immobilisation,
complicated
six weeks
of fibrous tissue occurs for up to six months.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE
Therefore
after
3.
an
assessment
an interval
The
has
only
end
efficient
rarely
of
of at least
subjective
been
results
sufficient
of patients
show slight
uninfluenced
appreciably
4. The only
treatment
strapping
or
at the
in
to cause
persistent
by the
a
OF
TREATMENT
the results
six months.
immobilisation
is this
adhesive
RESULTS
of
end
any
for
straight
spatula
of six months
hyperextension.
with
549
FINGER
treatment
are
should
satisfactory
patients
normal
in
order
to
relieve
made
only
or not
there
disability
any
activities.
the
be
whether
have
limitation
of movement,
of treatment.
of mallet
finger
is the
cases
splint
of
Few
interference
most
MALLET
method
deformity
and
type or duration
necessary
OF
A high
and
this
is seemingly
application
initial
and
proportion
of
elastic
discomfort
from
the injury.
REFERENCES
5. (1944):
BUNNELL,
J. MCK.
DUNCAN,
H0wIE,
Journal,
H.
46,
Surgery
(1948):
(1947):
The
of the Hand.
Philadelphia,
London,
of the Hand.
British Journal
Treatment
of Mallet Finger.
A Modified
Trauma
Montreal:
J. B. Lippincott
of Surgery,
35, 397.
Plaster
Technique.
New
Company.
Zealand
Medical
513.
M. L. (1930):
Rupture
of Tendons
of the Hand.
Surgery,
Gynecology
and Obstetrics,
50, 611.
D. R. (1952):
Internal
Splint for Closed and Open Treatment
of Injuries
of the Extensor
Tendon
Distal Joint of the Finger.
Journal
of Bone and Joint Surgery,
34-A, 785.
RATLIFF,
A. H. C. (1947):”
Mallet
“Finger.
A Review of 45 Cases.
Manchester
Medical
School Gazette,
ROSENZWEIG,
N. (1950):
Management
of the Mallet Finger.
South African
Medical
Journal,
24, 831.
SMILLIE,
I. S. (1937):
Mallet
Finger.
British
Journal
of Surgery,
24, 439.
WATSON-JONES,
R. (1940):
Fractures
and Other Bone and Joint Injuries.
Edinburgh:
E. & S. Livingstone.
WATSON-JONES,
Sir R. (1956): Fractures
and Joint Injuries.
Fourth
edition,
Vol. 2, p. 645.
Edinburgh
London:
E. & S. Livingstone
Ltd.
WILLIAMS,
E. G. (1947):
Treatment
of Mallet Finger.
Canadian
Medical
Association
Journal,
57, 582.
MASON,
PRATT,
VOL.
41 B,
NO.
3,
AUGUST
1959
at the
26,4.
and