FINGER

 INJURY  

Dr.  M.  Sak2  SpOT  

 h7p://radiographics.rsnajnls.org/cgi/content-­‐nw/full/24/4/1009 /F2  

h7p://www.hughston.com/hha/b_16_4_2a.jpg  
MALLET  FINGER  
-­‐  Mallet  finger  is  disrup2on  of  the  terminal  
extensor  tendon  to  the  distal  phalanx  
-­‐  May  be  doe  to  direct  trauma  but  more  oWen  
follows  tendon  rupture  when  the  finger  2p  is  
forcibly    bent  during  ac2ve  extension    
-­‐  The  terminal  joint  is  held  flexed  and  the  pa2ent  
cannot  straighten  it  but  passive  movement  is  
normal.  With  the  extensor  mechanism  
unbalance,  the  proximal  interphalangeal  joint  
may  become  hyperextended  
-­‐  Synonyms:  Drop  finger;  Baseball  finger  
 Mallet  Finger   1

•  Mechanism  of  Injury   •  Exam  Deficit  

–  Flexion  force  or  axial  loading   –  Ac2ve  Extension  (Extensor  
during  DIP  extension.   Lag).  
–  Terminal  extensor  tendon   •  Imaging  
avulsion.  
–  AP,  lateral,  oblique.  
•  Presenta2on  
–  DIP  Flexion  +/-­‐  edema.  

h7p://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformi2es.pdf  

h7p://www.eorthopod.com/images/ContentImages/hand/finger_mallet/finger_mallet_diagnosis01.jpg  

1.  h7p://books.elsevier.com/bookscat/samples/9780323033862/Chapter_15_Common_Finger_Sprains_and_Deformi2es.pdf  
 Mallet Finger

http://www.eorthopod.com/images/ContentImages/hand/finger_mallet/finger_mallet_intro01.jpg
DIAGNOSIS  
Signs  and  Symptoms  
-­‐  The  DIP  joint  of  the  involved  finger  is  held  in  
flexion,  and  ac2ve  extension  is  lost;  full  passive  
extension  usually  is  present.  
-­‐  Hyperextension  of  the  PIP  joint  also  may  be  
observed.  
Physical  Exam  
-­‐  Document  the  integrity  of  the  skin  and  nail  bed.  
-­‐  Note  ac2ve  and  passive  extension  (and  flexion  if  
not  acute).  
-­‐  Observe  the  status  of  the  proximal  joints.  
-­‐  Diagnosis  is  based  on  physical  examina2on  with  
radiographs  to  assess  for  fracture.  
 
TYPES  OF  MALLET  FINGER  
T  here  are  three  types  
 1.  a  tendinous  avulsion  
 2.  a  small  flake  of  bone  
  3.   a   large   dorsal   bone   fragment,   some2mes  
 with    subluxa2on  of  the  joint  
 
TREATMENT  

-­‐  Full-­‐2me  splin2ng  of  the  DIP    joint    for  6  weeks,  

followed  by  6  weeks  of  night  splin2ng  
-­‐  Ar2cular  fractures  involving  less  than  25  percent  
of  the  joint  and  without  subluxa2on  are  treated  
the  same  way  as  a  tendonous    mallet  finger  
-­‐  Large  ar2cular  fragments  or  joint  subluxa2on  are  
treated  with  ORIF  for  displaced  dorsal  base  
fractures  comprising  >25%  of  ar2cular  surface  
-­‐  This  posi2on  is  held  con2nuously  for  6-­‐8  weeks    
-­‐  An  acut  mallet  finger  should  be  splinted  with  
joint    in  extension  for  8  weeks  
 
TREATMENT  
 SUBUNGUAL  HEMATOMA  
•  A  subungual  hematoma  is  a  collec2on  of  
blood  underneath  a  toenail  or  fingernail  
(collec2on  of  blood  in  the  space  between  the  
nailbed  and  nail).    
 E/ology  
•  Most  commonly  form  aWer  a  crush-­‐type  injury  to  
the  2p  of  the  finger  or  toe.  
•  This  injury  can  occur  in  many  ways:  
–  Hikng  your  finger  with  a  hammer  
–  Dropping  a  heavy  object  on  your  toe  
–  Closing  your  finger  in  a  door  

•  Occur  over  2me  from  pressure  over  2me  

(wearing  shoes  that  are  too  small  while  prac2cing  
or  compe2ng).    
 Symptoms  
•  A  discolora2on  of  red,  maroon,  or  other  dark  
color  beneath  the  nail  aWer  an  injury.  

•  The  most  common  symptom  is  intense  pain.  

–  Pressure  generated  between  the  nail  and  the  
nailbed,  where  the  blood  collects,  causes  this  
pain.  
–  The  pain  may  also  be  caused  by  other  injuries  
such  as  a  fracture  to  the  underlying  bone,  or  
bruising  to  the  finger  or  toe  itself.  
 Medical  Treatment  
•  Subungual  hematomas  are  treated  by  either  releasing  
the  pressure  by  drilling  a  hole  through  the  nail  into  the  
hematoma  (trephining)  or  by  removing  the  en2re  nail.  
•  Removal  of  the  nail  is  typically  done  when  the  nail  
itself  is  disrupted,  a  large  lacera2on  requiring  suturing  
is  suspected,  or  there  is  a  fracture  of  the  2p  of  the  
finger.  
 
•  Frequently,  the  finger  or  toe  is  numbed  with  a  digital  
block.  
–  A  numbing  medica2on  such  as  lidocaine  is  injected  at  the  
bo7om  of  the  finger  or  toe.  
The  process  of  burning  a  hole  in  the  nail  to  
relieve  the  hematoma.  No2ce  the  blood  
draining  from  the  hole  aWer  the  hole  was  
formed  with  the  cautery  unit's  hot  2p.  The  
finger  has  been  numbed  prior  to  this  
procedure.  
–  Needle:  A  large  diameter  needle  is  used  to  drill  or  
bore  into  the  nail  to  create  a  hole  to  allow  the  
blood  to  drain  out.    
–  Paper  clip:  This  technique,  although  an  older  one,  
is  s2ll  used  by  some  prac22oners.  A  paper  clip  is  
opened  so  that  the  pointed  end  is  free.  Then  the  
pointed  end  is  heated  up,  usually  by  passing  it  
through  a  flame,  and  used  to  burn  through  the  
nail.  This  technique  uses  a  combina2on  of  the  
cautery  method  and  the  needle  method.  
•  AWer  the  nail  has  been  drained,  soak  the  finger  
or  toe  in  iodine  solu2on  for  10  minutes.  

•  Cover  the  area  with  a  sterile  dressing  and  apply  

a  protec2ve  splint  for  24-­‐48  hours.  

•  Check  carefully  for  signs  of  infec2on  (including  

redness,  pain,  heat,  and  drainage  from  the  
wound).    
 Follow-­‐up  
•  AWer  the  draining,  follow-­‐up  is  usually  not  
necessary.  
•  If  there  was  a  fracture  à  an2bio2cs.  
•  If  the  nail  was  removed  and  a  cut  in  the  nailbed  
was  s2tched  closed  à  re-­‐examina2on  in  48-­‐72  
hours.  
–  Usually,  the  type  of  sutures  (s2tches)  placed  will  
dissolve,  so  removal  is  not  needed.  
–  If  nondissolvable  sutures  (nylon)  are  placed  in  a  
nailbed  lacera2on  à  removed  in  about  7  days.  
–  Close  monitoring  is  s2ll  recommended