TECHNIQUE

Percutaneous Tenodermodesis for Mallet Fingers:

An Office-based Procedure
Kjell Van Royen, MD, Mohammed Muneer, MD, and Tsu-Min Tsai, MD

Abstract: Mallet fingers are injuries to the extensor tendon at the

distal interphalangeal (DIP) joint and can present as a bony avulsion or
as a soft tissue injury. Nonbony mallet fingers are frequently splinted in
extension between 6 and 8 weeks. If splinted correctly, most results are
good with a mean DIP joint extension lag between 5 and 10 degrees.
However, decreased swelling, hygienic considerations and patient
compliance can lead to splint removal and a less favorable outcome. We
present a percutaneous tenodermodesis using only a digital block and a
4.0 nylon suture. This office-based procedure provides joint reduction
and prevents joint movement during the immobilization period. The
suture can be removed after 8 weeks, allowing active mobilization of
the DIP joint. We present the results of 8 patients with a mean follow-up
of 3 months and mean initial extension lag of 32 degrees, resulting in a
mean final extension lag of 2 degrees and excellent outcomes using the
Crawford criteria.
FIGURE 1. Illustration of technique.
Key Words: mallet finger, tenodermodesis, office-based
(Tech Hand Surg 2021;25: 56–58) The technique is performed in the office with field steri-
lity. The skin of the affected finger is disinfected with an
alcohol solution and a digital block is performed. We use 3 mL
mallet finger represents an injury to the insertion of the of xylocaine with 1 injection to the volar side of P2. After
A extensor tendon at the dorsal base of the distal phalanx
and includes both soft tissue and bony avulsions.1 It is a
application of the local anesthetic, we wait around 20 minutes
for the finger to become numb. In case of extension deficit,
common injury with an incidence of 9.9 per 100,000 individ- passive mobilization of the DIP joint is performed with the
uals per year2 and is caused by an axial load to the finger MCP joint flexed 90 degrees to obtain full extension of the DIP
followed by hyperflexion or hyperextension of the distal joint. The hand is then positioned in full pronation on the table
interphalangeal (DIP) joint.3 Soft tissue injuries without bony while the patient is sitting in a chair. The finger is again dis-
avulsion are more common4 and have been treated both oper- infected with an alcohol solution and is held in 5 degrees of
ative and nonoperative.5 Most authors advise a nonoperative hyperextension by an assistant. A 4.0 nylon suture is applied to
treatment with a DIP extension splint and an immobilization the dorsal side in a transverse fashion 5 mm proximal to the nail
period of 6 to 12 weeks.6,7 Although the mean extension lag skin junction through the skin and underlying extensor tendon.
throughout literature is around 5 to 10 degrees,8,9 the deficit can The same procedure is repeated with the same 4.0 nylon suture
be much higher in some patients, resulting in functional or 10 mm proximal to the DIP joint. Again, the suture is placed
cosmetic impairment and patient dissatisfaction.10 through the skin and underlying extensor tendon. With the DIP
We propose an office-based technique to treat mallet fin- joint held in 5 degrees of hyperextension, the 2 ends of the
ger deformity that uses one nylon suture to reduce the DIP joint threads are tensioned and sutured in a figure of 8 fashion (Fig. 1).
in full extension. The aim of this study is to determine DIP joint
extensor lag after the percutaneous tenodermodesis technique.
We hypothesized this technique to prevent DIP joint extensor
lag after mallet finger deformity.

MATERIALS AND METHODS

A retrospective chart study was performed on patients that were
treated with the percutaneous tenodermodesis technique.
Patients with open injuries, bony injuries and follow-up <8
weeks were excluded from the study.

From the Christine M Kleinert Institute for Hand and Microsurgery,

Louisville, KY.
Conflicts of Interest and Source of Funding: The authors report no conflicts of
interest and no source of funding.
Address correspondence and reprint requests to Tsu-Min Tsai, MD, 225
Abraham Flexner Way, Suite 850, Louisville, KY 40202.
E-mail: ttsai@kleinertkutz.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. FIGURE 2. Long finger treated with percutaneous tenodermodesis.

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Techniques in Hand & Upper Extremity Surgery  Volume 25, Number 1, March 2021 Percutaneous Tenodermodesis

FIGURE 3. Result of left small finger treated with percutaneous tenodermodesis after removal of suture.

After verification of complete DIP extension, a dressing with a
volar aluminum splint from the proximal interphalangeal joint to
the fingertip is applied.
The dressing is kept in place for 1 month and active mobi-
lization of the proximal interphalangeal joint is encouraged. After
1 month, the splint and dressing are removed (Fig. 2), and a pro-
tective splint is applied for 1 more month. After 2 months, the splint
and sutures are removed in the office and the patient is encouraged
to start active movement of the DIP joint (Fig. 3).
RESULTS
Between 2015 and 2019, 11 nonbony mallet fingers were
treated with the percutaneous tenodermodesis technique by the
senior author (T.-M.T.). One patient had an open lesion and 2
patients were lost to follow-up. Eight patients had at least 8
weeks of follow-up (Table 1). Mean patient age was 44 (range:
18 to 62). In total, 1 thumb, 2 long fingers, 2 ring fingers, and 3
small fingers were treated. Mean delay after initial trauma was 5
weeks (range: 0 to 24 wk) Mean follow-up was 12 weeks
(range: 8 to 16 wk). Mean initial DIP joint extension lag was 32
degrees (range: 15 to 50 degrees). Mean DIP joint extension lag
at final follow-up was 2 degrees (range: 0 to 5 degrees). No
patients had residual pain at final follow-up. No infections or
suture failures were encountered.
DISCUSSION
Closed soft tissue mallet fingers are common injuries and can
be treated conservatively with an extension splint.12 The
Crawford classification11 is the most commonly used to assess
the clinical outcome of mallet fingers and results are considered
excellent when the extension lag is <10 degrees without any
notion of pain. O’Brien and colleagues found that conservative
treatment with an extension splint gives an average 5 degrees
extension lag with an excellent result in 64% of cases. They
also found that 16% has only a fair result, with an extension lag
above 25 degrees.13
Many authors believe that the DIP joint should be
immobilized continuously for 6 to 8 weeks for 24 hours a day.
Decreased swelling of the finger, hygienic considerations and
lack of patient compliance can all lead to suboptimal
immobilization.14–16 This allows joint mobilization and dis-
traction of the healing tendon, resulting in extension lag.
In this study, we describe a technique to immobilize the DIP
joint with a percutaneous suture. Our data show that it gives
excellent results in 100% of patients, without the need of open
surgery or Kirschner-wire fixation. Although we immobilize
patients with a splint to protect the suture during daily activities, it
is not strictly needed to immobilize the joint. Patients can remove
the splint for hygienic considerations and decrease of swelling
will not lead to mobilization of the joint.
The suture material should be strong enough to keep the
joint in extension. Although we did not encounter any problems
with the 4.0 nylon, patients can theoretically tear the suture with
active flexion. Direct trauma to the finger with an unprotected
suture may also lead to a suture breakage. Patient education
with respect to protection and prevention of active DIP joint
flexion is important to obtain a good result.
Possible complications in this technique are skin infection,
septic tenosynovitis of the extensor tendon, skin breakage and
suture failure. We therefore advise the suture site to be kept
clean and dry and recommend caution in diabetic or immune
compromised patients. In our patient group, no complications
were encountered.

TABLE 1. Study Results

Patient No. Age (y) Finger Follow-up (wk) Initial Lag (deg.) Final Lag (deg.) Pain (0-10) Crawford Result11
1 21 5 12 −20 0 0 Excellent
2 62 3 10 −35 −5 0 Excellent
3 43 4 12 −25 0 0 Excellent
4 18 1 12 −15 0 0 Excellent
5 62 5 12 −40 −5 0 Excellent
6 53 3 14 −40 −5 0 Excellent
7 40 4 8 −30 0 0 Excellent
8 54 5 8 −50 0 0 Excellent
Mean 44 12 −32 −2 0
From Crawford.11

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Van Royen et al Techniques in Hand & Upper Extremity Surgery
This study has some limitations. It is a retrospective study
with a small cohort and short follow-up time. First, a larger
population could show complications that were not encountered
in our cohort. Second, extension lag could develop after
removal of the sutures and start of active mobilization. Two
patients in our study did not follow-up after suture removal and
this might cause a possible underestimation of the final exten-
sion lag. However, we did not encounter this rebound effect in
any of the patients that did follow-up after suture removal and
Foucher et al8 did not find any difference in outcome between
short-term and long-term evaluation.
In conclusion, we think the percutaneous tenodermodesis is
a quick, inexpensive and safe technique. It has good preliminary
outcomes and the results seems to be less dependent upon
uninterrupted immobilization or patient compliance.
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