Mallet Finger: Understanding the Condition, Treatment Options, and the Importance of Proper Care
By Dr. Oren Michaeli, DO – Board Certified General Surgeon, Fellowship-Trained in Hand Surgery, Microsurgery, and Peripheral Nerve Surgery
As a board-certified surgeon fellowship-trained in hand and microsurgery, I have seen firsthand how something as seemingly minor as a mallet finger can significantly impact a person’s daily life. If left untreated or improperly treated, mallet finger injuries can lead to chronic deformity, reduced hand function, and long-term discomfort. In this blog post, I will explain what mallet finger is, why it occurs, the most commonly recommended treatments, and what can happen if you choose not to treat it. I will also discuss why I favor pinning for certain cases—especially for bony mallet fingers—using the Ishiguru (block pinning) technique.
What Is a Mallet Finger?
A “mallet finger” refers to an injury involving the extensor tendon at the tip of the finger. The extensor tendon is responsible for straightening or extending your fingertip. When the tendon is damaged or torn at its insertion on the bone—or when a small piece of bone (an avulsion fragment) is pulled away—the fingertip can no longer fully straighten and remains in a flexed (bent) position at rest. This characteristic droop at the fingertip is what we call a “mallet.”
This is a rendering of what is happening under the skin when a simple (none-bony) mallet finger occurs.
Causes
Trauma: Most often, a mallet finger occurs when the fingertip is forcefully bent, typically during sports (e.g., catching a ball) or other high-impact activities.
Direct Impact: Even a relatively minor impact or catching the fingertip awkwardly can pull or tear the extensor tendon from its insertion.
Bony Avulsion: Sometimes, a piece of bone is pulled off with the tendon, leading to a “bony mallet.” This type can alter the treatment plan depending on the size and displacement of the bone fragment.
A Lighthearted Look at How Mallet Fingers Happen
Despite the often serious consequences of a mallet finger, the ways people injure their fingertips can be surprisingly humorous. I’ve had a patient who bravely tried to puncture the paper seal on a jar of peanut butter using just their finger—and walked away with a mallet injury. Another patient developed one merely by tucking in the corner of their bedsheets a little too forcefully. And then there was the gentleman who managed to injure his fingertip while hurriedly tucking in his pants. Since these everyday mishaps can make for less-than-heroic tales, I sometimes half-jokingly suggest patients tell everyone they injured themselves saving a busload of innocent children from a rogue grizzly bear. After all, a dramatic story can at least add a small silver lining to an otherwise frustrating finger injury!
Symptoms and Diagnosis
Droop at the Fingertip: The fingertip may rest in a bent position and cannot be actively extended.
Tenderness and Swelling: Some patients note pain, swelling, and mild bruising at the back of the finger near the nail joint.
Difficulty with Hand Function: Simple tasks like typing, buttoning a shirt, or grasping objects may be more challenging.
Diagnosis typically involves a clinical examination and standard X-rays. X-rays help clarify whether the injury is purely tendinous (no bone involvement) or bony (with an avulsion fracture). Identifying which type of mallet finger you have is critical for guiding treatment.
Treatment Options
1. Splinting (Conservative Treatment)
A conventional and time-tested method for treating mallet finger—especially when there is minimal bone involvement or the fracture fragment is very small—entails wearing a splint. This splint holds the fingertip in continuous extension for several weeks to allow the tendon to heal in a proper, tensioned position.
Duration: Commonly 6–8 weeks, sometimes longer, depending on the healing response.
Compliance: The key challenge is that the finger must remain fully extended at all times, even during bathing. If the fingertip flexes (bends) at any point, the healing process can be disrupted, necessitating another full cycle of splinting.
Pros: Non-invasive, widely available, and often quite effective for small or non-displaced injuries.
Cons: Patient compliance can be difficult. Maintaining personal hygiene with a finger splint can be cumbersome and disruptive to daily activities.
2. Pinning (Surgical Stabilization)
When patients have either a larger bony fragment or a purely tendinous mallet finger but wish to avoid the demands of strict splint compliance, surgical pinning is an excellent option. My personal preference—based on experience and patient outcomes—is to favor percutaneous pinning. This approach has distinct advantages:
Minimal Invasiveness: A small pin is placed across the joint (DIP joint) to hold the fingertip in extension.
Office Procedure: Pinning can be performed in the office setting under local anesthesia. The procedure itself is quick—often taking only around five minutes.
Improved Hygiene: Once the pin is in place, patients can usually shower and carry out regular hand washing without worrying about removing or replacing a splint, thereby reducing the risk of skin issues and improving overall comfort.
Reduced Need for Patient Compliance: Unlike splinting, the finger is stabilized internally. The patient does not need to worry about the splint shifting or the fingertip accidentally bending.
Bony Mallet and the Ishiguru (Block Pinning) Technique
For bony mallet injuries, where there is a sizable avulsion fracture, I exclusively offer block pinning using the Ishiguru technique. In this method, the fracture fragment is precisely reduced, and pins are placed to ensure stable fixation and proper joint alignment. This technique helps achieve anatomical reduction of the fracture, promoting more predictable healing and reducing the risk of future complications like joint incongruity or persistent deformity.
What If a Mallet Finger Goes Untreated?
It is important to understand the potential long-term consequences of ignoring a mallet finger:
Permanent Deformity: The finger may remain in a drooped position, leading to functional difficulties with tasks requiring finger extension.
Swan Neck Deformity: Over time, untreated mallet fingers can contribute to an imbalance across the finger joints, causing hyperextension at the proximal interphalangeal (PIP) joint and flexion at the distal joint—a deformity known as a “swan neck.”
Arthritis and Stiffness: In some cases, chronic misalignment can accelerate wear on the joint surfaces, leading to pain, stiffness, and arthritic changes over time.
Swan Neck Deformity
Swan neck deformity features hyperextension of the proximal interphalangeal (PIP) joint and flexion of the distal interphalangeal (DIP) joint, resembling a swan's neck. It occurs from an imbalance in hand muscles and tendons. This imbalance results in improper joint alignment and the typical finger position.
These potential outcomes underscore the importance of proper treatment—whether via meticulous splinting, pin fixation, or another surgical procedure.
Recovery and Aftercare
Splint Aftercare
Duration: The finger is kept in extension for 6–8 weeks, sometimes longer.
Skin Care: Regularly inspect the finger for skin breakdown or irritation; the splint must be kept clean and dry.
Rehabilitation: Once splinting is complete, a gradual return to normal hand use may require exercises guided by a hand therapist.
Pinning Aftercare
Pin Site Care: Keep the pin site clean and monitor it for any signs of infection (e.g., redness, drainage, increased pain).
Activity Restrictions: Avoid heavy gripping or tasks that put undue stress on the stabilized fingertip while the pin is in place.
Pin Removal: The pin is typically removed in the office after sufficient healing time (often a few weeks).
Therapy and Strengthening: After pin removal, your surgeon may recommend exercises or therapy to restore flexibility and strength in the fingertip and hand.
Conclusion
A mallet finger may initially appear minor, but without proper care, it can lead to functional limitations and persistent deformities. Treatment options primarily revolve around splinting or surgical fixation—often with pinning. My practice favors pinning for many patients because it reduces the compliance burden, offers straightforward hygiene, and can yield faster, more predictable functional outcomes. Bony mallet injuries, in particular, often benefit from the Ishiguru technique for block pinning, providing excellent alignment and stability during healing.
Whether you are an active individual or simply looking to maintain hand function for daily tasks, seeking timely intervention for a mallet finger is paramount. Consultation with a hand surgeon will help determine the best course of action, taking into account the specific nature of your injury, your daily routine, and your long-term goals for hand functionality.
Why Choose Dr. Oren Michaeli at Hand, Nerve & Microsurgery PC?
Expertise in Mallet Finger and Complex Hand Injuries
As a board-certified general surgeon fellowship-trained in hand, nerve, and microsurgery, I bring specialized expertise to every case. Mallet fingers often involve subtle damage to the extensor tendon or bony attachments, and I have extensive experience managing these delicate structures to ensure proper alignment and healing.
Thorough, Patient-Centered Care
No two mallet finger injuries are exactly alike. I take a detailed, individualized approach to each patient—evaluating the extent of tendon or bony involvement, discussing your activity level and daily needs, and formulating a treatment plan that aligns with your lifestyle. Whether through meticulous splinting, pinning, or advanced surgical techniques, my priority is restoring function and reducing long-term complications.
Advanced Techniques
From minimally invasive pinning procedures to the Ishiguru (block pinning) technique for bony mallet injuries, I utilize the most current and evidence-based approaches. These methods can help stabilize the finger quickly, reduce the burden of strict splint compliance, and often result in faster recovery times.
Comprehensive Support
My dedicated team and I will guide you through each stage of treatment—from initial diagnosis to post-operative care. We understand the importance of clear communication and seamless coordination with insurance providers, making every effort to streamline your experience so you can focus on healing.
Scheduling a Consultation
If you suspect you have a mallet finger or are experiencing a fingertip droop that limits your normal hand function, don’t delay seeking professional evaluation and treatment. Early intervention can prevent permanent deformities, swan neck deformities, and arthritic changes.
Phone: (212) 540-4263
Email: Info@handnervemicrosurgery.com
Office: 570 Sylvan Ave, 2nd Floor, Englewood Cliffs, NJ 07632
Insurance Support: We often arrange for insurance to cover surgical treatment, even if we are out-of-network. Our administrative team will handle the details to help ensure you receive the care you need without added stress.
Disclaimer
This information is for educational purposes and should not replace professional medical advice. If you suspect you have a mallet finger or any hand-related injury, please contact a qualified hand surgeon or healthcare professional for a comprehensive evaluation.
