Mallet Finger: What Is It And How Do I Fix It?

A patient of mine came into the office last week complaining she couldn't straighten out her finger any more.
Two weeks ago she had been playing Volleyball and took a ball off the tip of her right ring finger. She said she could still continue playing despite the pain, but since then hadn't been able to straighten the tip of that finger any longer.



Mallet Finger: What Is It?
This very pleasant lady had suffered a tear to the extensor tendon of her ring finger. The mechanism of injury was classic. People will typically describe a direct blow to the affected finger when it is fully extended (ie straightened out). This usually will be a ball striking the tip of the finger, but occasionally happens when they run into something/someone with the finger straight out. With the tip of the finger straight, the force of the blow ends up tearing the extensor tendon off the bone, and the individual can no longer lift or straighten up the last joint of the finger.



When the tendon is torn away, it takes a little chip of bone with it, and is readily seen on plain x-rays (above).

How Do I Diagnose It?
First, my suspicion is quickly aroused with the typical history of injury. Secondly, to examine the finger, the diagnosis is usually confirmed seeing the tip of the finger hanging down (looks like a mallet, thus the nickname!)


The patient, when asked, will NOT be able to lift, or extend, the tip of the finger, confirming that the tendon is ruptured. Finally, for confirmation, I will take an x-ray to both confirm the diagnosis, and ensure that not too large a piece has broken away, and that the joint is still reasonably intact.

How Do I Fix It?
For the vast majority of patients, using a splint, HYPEREXTENDING the tip of the joint for a period of about 6 weeks allows the torn extensor tendon to reattach itself and heal.


There are commercially available splints, but I find they often don't fit snugly enough, and don't hyperextend the joint far enough. Much easier, at least for me, is to cut a piece of aluminum splint to the right length, and bend it to the degree of extension I want. Most IMPORTANTLY, I make sure that the middle joint of the finger is allowed to continue moving freeely, so that it doesn't stiffen over the period of immobilization. I also tell patients that when they are changing the tape, or cleaning the finger, to keep holding the tip of the finger in hyperextension, and NOT let it fall back down, ensuring that the torn tendon remains in contact and continues healing. I will sometimes tell them that if they let this happen, their 6 week clock has to restart again!

On rare occasions, the chip of bone is too large, or the joint is out of alignment. In these cases, I will send patients on to a plastic surgeon to discuss surgically correcting the digit. I will also, on occasion, depending on the person's occupation (ie professional piano player, etc), send them for a surgical opinion irregardless.

Final Note: I like to follow up with these individuals after 4-6 weeks and get a new xray and examine them again to ensure healing.

Have you ever suffered this injury? How was it treated? How did everything turn out?
Let me know!

Quick Hit For Asthmatics: A New Add on Drug?

In a new article published this week in the New England Journal of Medicine, (full article here), adding the long acting anticholinergic drug, tiotropium, or Respimat, to poorly controlled asthmatics current treatment, significantly improved their symptoms.

People with asthma can have a tough go with simple daily activities, with triggers ranging from smoke, to pets, to pollens, to household dust. They can have trouble in the cold, with exercise, and anyone who has felt their breathing feel tight on occasion can sympathize with the sensation of this disease.



Respimat is a soft mist inhaler taken twice daily, and in this study of asthmatics between the ages of  18-75, their breathing was significantly improved.

Now, these individuals had severe asthma, that was poorly controlled, despite already using long acting steroid inhalers in addition to long acting beta agonists. They were also allowed to continue using short acting rescue medications if needed.

Results showed significant improvements in FEV1 (forced expiration volume in 1sec), or how strongly they could exhaled their air out, as well as preventing severe flare ups of their disease.

Side effects of the medications were similar to the placebo group.


Bottom Line: This is an interesting addition to the regimen of asthma medications, when control is difficult despite usual therapy.

Whooping Cough: Making A Comeback?

With kids going back to school, and in close quarters with their mates, it might be worthwhile revisiting a bug making a bit of a comeback.

In our city, there was a small spike of whooping cough (pertussis) over the summer, with half of them coming from unvaccinated kids. Other reported increases have been occurring within the province, within Canada, and within the U.S.

What Is Whooping Cough?
Whooping Cough, or Pertussis, is a highly infectious bacteria. First described in the year 1679, Bordetella pertussis translates as "violent cough". The Chinese coined the phrase "the cough of 100 days" because of its chronic nature.

The classic inspiratory whoop following a paroxysmal cough in children is not always present, especially in teens and adults and may contribute to some missed diagnoses. Other typical features include a cough lasting more than 2 weeks, sudden onset coughing spells, sometimes associated with vomiting. Fever is often NOT present or low.

How Do You Catch It?
The actual bug is a gram negative coocobacillus that is slow growing and highly virulent, meaning that those people who are exposed and unvaccinated are very likely to contract the disease. Attack rates range from 90-100 percent when NOT vaccinated. Transmission is by exposure to respiratory droplets from infected individuals.

Before vaccines were given against Pertussis in the 1940's, upwards of 200,000 cases of pertussis were reported annually in the United States. Epidemics spiked every 3-4 years without respect to seasons.
Infection rates decreased 150 fold after introducing vaccines, and spikes continue to occur when vaccination rates decline. (Britain saw a huge spike several years ago when there was unwarranted concern with respect to links to autism.)

Classic Presentation
The classic presentation is in 3 stages; Catarrhal stage, Paroxysmal stage, and Convalescent stage.
In the Catarrhal stage, lasting 1-2 weeks, the individual feels rundown with mild cough, perhaps low grade fever and runny nose. (Like a common cold.)

The Paroxysmal stage can last 2-4 weeks and is when people get more concerned. The cough is defined as sudden, repetitive coughing with up to 10-30 coughs per spasm. A whoop may or may not follow, and is more common in kids than older individuals. Posttussive vomiting is not uncommon, and fever may or not accompany this phase.

The Convalescent, or recovery stage, can last months and the cough should decline, but may continue to wax and wane.



Diagnosis and Treatment
Diagnosis is often clinical, but definitive diagnosis is by having a nasopharyngeal swab done. The time to diagnosis is several days, and treatment should probably get started prior to final diagnosis. First line treatment is straight forward and effective, so see your physician sooner than later.

Finally, immunization for both kids and ongoing boosters for adults should be the critical preventive method.
Immunity against pertussis wanes, and in Ontario, we have added the acellular pertussis vaccine to our tetanus booster given every 10 years.

Epidemics in schools should prompt review of your kids boosters, as well as your own.
I strongly advocate following our immunization program.

Let me know what you think.
Have you had any local outbreaks where you are?