Hand Case 4

History and Physical27yo male presents

after hearing snap and having sudden pain in right index finger tip after throwing a fastball during semi-pro baseball league. Pt has pain limited to DIP joint of right index finger; denies any other injuries

T 98.3 P 88 BP 128/63 O2 98%

Gen: minimal pain, NADMSK: swelling to right

index DIP joint, which is in slightly flexed position. Pt unable to fully extend at DIP joint when isolated

Neuro: Motor 5/5 throughout except at DIP joint, sensory in tact.

Radiographs

Diagnosis: Mallet Finger (with fx)

Terminal extensor tendon disruption with associated avulsion fracture

For simple Mallet finger without fracture, can splint ONLY DIP joint in extension for a minimum of 6 weeks (usually) 10, with ortho follow up before removal of splint

Mallet Finger with associated avulsion fx can be treated same way unless there is fx displacement of more than 40 % of articular surface or w/ volar subluxation of distal phalanx;

ED Management

Occurs from forcible flexion of the extended DIP joint: following this injury there is unopposed flexion from the FDP; w/ severe flexion deformity of DIP joint in mallet finger injury a

secondary hyperextension deformity of PIP (swan neck) joint may occur because of imbalance of the extensor mechanism;

Be sure to get true lateral to r/o avulsion fx or fx of articular surface; volar subluxation along w/ a significant intra-articular fx

(greater than 30% of joint surface) is an indication for surgery;

DO NOT immobilize PIP joint, and stress that finger must be CONTINUOUSLY in hyperextension for at least 6 weeks If finger comes out of Splint, 6 week clock is restarted

Untreated, or poorly treated, may also lead to swan neck deformity.

Pearls

More Images

http://www.wheelessonline.com/ortho/mallet_fractures_dup_of_496

http://www.eorif.com/WristHand/MalletFinger.html

http://www.hughston.com/hha/a_16_4_2.htmhttp://www.holidayparkphysicalrehab.com/

article.php?preview_aid=287

References