EVIDENCE-BASED MEDICINE
Soft Tissue Mallet Finger Injuries With Delayed Treatment
Nina Suh, MD, Scott W. Wolfe, MD
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THE PATIENT
A 47-year-old right-handed man presents 12 weeks
after jamming his extended distal interphalangeal (DIP)
joint with a basketball. He did not seek immediate
From the Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, and Weill Med-
ical College of Cornell University, New York, New York.
Received for publication March 25, 2013; accepted in revised form March 25, 2013.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Correspondingauthor: ScottW.Wolfe,MD,DepartmentofHandandUpperExtremitySurgery,
Hospital for Special Surgery, 535 East 70th St., New York, NY 10021; e-mail: wolfes@hss.edu.
0363-5023/13/38A09-0027$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2013.03.050
©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1803
Evidence-Based Medicine
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Learning Objectives
• Discuss the treatment options for chronic mallet finger injuries.
• List surgical options for the treatment of chronic mallet finger injuries.
• Explore the role of splinting in the overall management of chronic mallet finger injuries.
• Review the indications for surgical treatment of chronic mallet finger injuries.
• Asses the outcomes and possible complications after surgical treatment of chronic mal-
let finger injuries.
Deadline: Each exam purchased in 2013 must be completed by January 31, 2014, to be
eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to
complete each month’s JHS CME activity is 2 hours.
Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.
medical attention and has not received any treatment.
He has a 25° extensor lag at the DIP joint and no
fracture is demonstrated on radiographs.
THE QUESTION
What is the most appropriate treatment for a soft tissue
mallet finger injury that presents in a delayed fashion?
CURRENT OPINION
Mallet injuries are characterized by soft tissue avulsion
or fracture of the insertion of the terminal extensor
tendon onto the distal phalanx typically after a forced
flexion or axial loading injury. In the elderly, relatively
 1804 SOFT TISSUE MALLET INJURY: DELAYED TREATMENT
minor trauma, such as when pulling up the bed sheets,
Evidence-Based Medicine
can result in a soft tissue mallet injury. Untreated or
late-presenting patients with a residual extensor lag may
develop swan-neck deformity.
For soft tissue mallet injuries that present weeks to
months after injury, management options include non-
operative prolonged extension splinting,1,2 tenoder-
modesis (en bloc resection of dorsal skin, scar tissue,
and capsule),3,4 central slip tenotomy,5– 8 spiral oblique
retinacular ligament reconstruction,9 and palmaris lon-
gus reconstruction.10 For swan-neck deformities, cen-
tral slip tenotomy5– 8 or spiral oblique retinacular liga-
ment repair9 is preferred.
THE EVIDENCE
Patel et al1 described continuous DIP joint extension
splinting for 10 weeks in 10 patients presenting a min-
imum of 4 weeks from injury with a soft tissue mallet
injury. The authors did not disclose the time of final
follow-up evaluation but reported 5 patients had no
residual extensor lag, 4 had less than 10° extensor lag,
and 1 had between 10° and 20° extensor lag. Two
recurrences developed within a week of splint discon-
tinuation but resolved with an additional 8 weeks of
extension immobilization.
Garberman et al2 retrospectively compared 21 acute
and 19 delayed mallet fingers treated for 6 to 10 weeks
with a splint. Final evaluations were made 2 to 6
months after initiation of treatment, and the authors
reported 15 of 19 patients with delayed mallet fingers
had a residual extensor lag of less than 10° compared
with 17 of 21 patients treated acutely.
Operative intervention options are also described in
the literature. Iselin et al3 performed tenodermodesis
and reported 22 of 26 patients with less than 10° of
extension lag. Meanwhile, Kon and Bloem4 reported 26
of 27 patients with an arc from 5° extension to 60°
flexion after tenodermodesis in patients with delayed
treatment or recurrent mallet deformity.
Lind and Hansen11 performed a procedure dubbed
“abbreviato” involving transection of the elongated ex-
tensor tendon and resuturing without tendon overlap at
the level of the DIP joint. They reported that 16 of 40
patients achieved full range of motion (ROM) and a
further 8 patients recorded less than 20° of extension
lag. Seven had minor improvement with a flexion lag
between 30° and 60°, and 9 had poor results with no
improvement or an increase in extension lag.
Ulkur et al12 used a suture anchor to attach the distal
extensor tendon to the distal phalanx in 22 patients with
mallet deformities diagnosed late and reported that 15
JHS 䉬 Vol A, September 
had no residual extensor lag, 5 had less than 10°, and 2
had a 10° to 20° extensor lag.
Gu and Zhu10 used a palmaris longus graft in 27
patients with acute lacerations of the extensor tendon
over the DIP joint and in 40 patients with mallet defor-
mities that presented in a delayed fashion and had
persistent deformity after 6 weeks of extension splint-
ing. The graft was sutured proximally to the remnant
extensor tendon and secured distally through a bone
tunnel through the distal phalanx. The authors reported
66 fingers had less than 10° of extension lag and less
than 20° of flexion loss, but they did not report the
results of delayed treatment separately.
Houpt et al7 reported that 26 of 35 patients treated
with central slip tenotomy at the level of the proximal
interphalangeal joint regained full extension of the DIP
joint, 8 patients had a residual extensor lag of 10° to
20°, and 1 patient had a lag of 30°. In another series of
20 patients, central slip tenotomy corrected all proximal
interphalangeal joint hyperextension deformities and
the extensor lag of the DIP joint was improved from an
average of 37° before surgery to an average of 9° after.6
Kleinman and Petersen9 used a spiral oblique reti-
nacular ligament reconstruction for 12 patients with
swan-neck deformity after mallet injury. Nine patients
had normal DIP joint extension and 3 had hyperexten-
sion of 10° to 25°. Two had a second operation to
address stiffness.
SHORTCOMINGS OF THE EVIDENCE
Only a few small retrospective case series are available
addressing delayed treatment of soft tissue mallet inju-
ries. Many of these are technique articles that provide
limited demographic and injury data and fail to describe
the splinting and exercise program in detail and focus
on a specific technique. The duration of evaluation and
the measurement and rating techniques are also vari-
able.
DIRECTIONS FOR FUTURE RESEARCH
Prospective randomized studies can ensure that patients
receiving each treatment are comparable and that the
evaluations are made at the same time using the same
criteria. Given that this problem is not very common, a
multicenter, prospective randomized controlled trial re-
porting residual lag, DIP joint motion, and all compli-
cations 6 to 12 months after completion of treatment
would be ideal. Comparisons should include no treat-
ment versus extended splint immobilization; nonopera-
tive versus operative treatment; and comparisons of the
various operative procedures.
 SOFT TISSUE MALLET INJURY: DELAYED TREATMENT
However, consideration should be made of the ap-
propriateness of studying this clinical entity on such a
large scale. The rarity of the diagnosis, the lack of
substantial functional impairment even in cases with a
residual DIP joint extensor lag associated with a mild
swan-neck deformity, and the lack of significant vari-
ability in the results of current single cohort studies
question the value of pursuing a largely aesthetic con-
cern at the cost of significant financial and logistical
resources.
OUR CURRENT CONCEPTS FOR THIS PATIENT
For patients who present more than a month after a soft
tissue mallet injury, we prefer to start with continuous
extension splinting of the DIP joint for 6 weeks. If an
extension lag persists after 6 weeks, we continue splint-
ing for another 4 to 6 weeks.
Given that residual DIP joint extensor lag is largely
an aesthetic rather than a functional concern, we favor
multiple attempts at nonoperative treatment with exten-
sion splints, even for recurrences. By and large, after we
attempt splinting for 12 to 14 weeks, most patients do
not proceed to surgical intervention because the residual
extensor lag is acceptable. Furthermore, surgical inter-
vention in our hands for delayed mallet deformities
does not reliably address aesthetic concerns. In the very
rare instance in which a patient presents with a delayed
mallet finger and concomitant swan-neck deformity
JOURNAL CME QUESTIONS
Soft Tissue Mallet Finger Injuries With
Delayed Treatment
What is the most preferred initial treatment
option for a symptomatic patient with chronic
soft tissue mallet finger injury?
a. Palmaris longus tendon graft
b. Suture anchor re-attachment of the terminal ex-
tensor tendon
c. Spiral oblique retinacular ligament reconstruction
d. Observation with or without stretching exercises
for 4 weeks
e. Extension splinting for 6 weeks
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JHS 䉬 Vol A, September 
1805
where we believe there may be some impact on func-
tion, we would offer a Fowler (central slip) tenotomy
without a trial of 3 months of splinting.
Evidence-Based Medicine
REFERENCES
1. Patel MR, Desai SS, Bassini-Lipson L. Conservative management of
chronic mallet finger. J Hand Surg Am. 1986;l l(4):570 –573
2. Garberman SF, Diao E, Peimer CA. Mallet finger: results of early
versus delayed closed treatment. J Hand Surg Am. 1994;19(5):850 –
852.
3. Iselin F, Levame J, Godoy J. Simplified technique for treating mallet
finger: tendermodesis. J Hand Surg. 1977;2(2):118 –121.
4. Kon M, Bloem JJ. Treatment of mallet fingers by tenodermodesis.
Hand. 1982;14(2):174 –176.
5. Bowers WH, Hurst LC. Chronic mallet finger: the use of Fowler’s
central slip release. J Hand Surg Am. 1978;3(4):373–376.
6. Grundberg AB, Reagan DS. Central slip tenotomy for chronic mallet
finger deformity. J Hand Surg Am. 1987;12(4):545–547.
7. Houpt P, Dijkstra R, Storm van Leeuwen JB. Fowler’s tenotomy for
mallet deformity. J Hand Surg Br. 1993;18(4):499 –500.
8. Lucas GL. Fowler central slip tenotomy for old mallet deformity.
Plast Reconstr Surg. 1987;80(1):92–94.
9. Kleinman WB, Petersen DP. Oblique retinacular ligament recon-
struction for chronic mallet finger deformity. J Hand Surg Am.
1984;9(3):399 – 404.
10. Gu YP, Zhu SM. A new technique for repair of acute or chronic
extensor tendon injuries in zone 1. J Bone Joint Surg Br. 2012;94(5):
668 – 670.
11. Lind J, Hansen B. Abbrevatio: a new operation for chonic mallet
finger. J Hand Surg Br. 1989;14(3):347–349.
12. Ulker E, Cengiz A, Ozge E, et al. Repair of chronic mallet finger
deformity using Mitek micro arc bone anchor. Ann Plast Surg.
2005;54(4):393–396.
Fowler central slip tenotomy procedure is
indicated for which of the following?
a. Any mallet finger deformity of 10°
b. Acute mallet finger deformity of 30°
c. Acute bony mallet finger deformity of 40°
d. Chronic mallet finger and concomitant swan-
neck deformity
e. Chronic soft tissue mallet finger and attenuated
central tendon