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!

Ankle Injuries: Do I Need An X-Ray?

Even if you're not a Yankees fan, you have to feel Derek Jeter's pain. Over the weekend, Jeter broke his ankle on a routine play, will miss the rest of the playoffs and may need surgery to correct the injury. Seeing such a class act and team leader go down is tough.



All of us have turned our ankle at some time as well. Be it running the bases, coming down from a rebound, sprinting down the soccer pitch, or simply stepping off the curb, we likely have rolled an ankle at some point. Ankle sprains themselves can be extremely painful, but when is the injury bad enough we may have broken something? Should you go to the ER and get an xray to be sure?

First off, sprains and breaks can both be disabling. To define a sprain, we are talking about injuring ligaments about the ankle, usually on the lateral (outside) part of the foot. This is because these ligaments are more mobile than the inside of the ankle.



Fractures are breaks of bones in the ankle and foot, again, usually on the lateral side of the foot, because the usual mechanism of injury is rolling the ankle in this direction.

So, When Should I Go Get An X-Ray?
Deciding to go the hospital after an ankle injury can sometimes be tough. If it's just a sprain, there's not a lot to be done, other than rest, elevate, and ice. If it's broken, you may need casting, an operation, who knows?
The cost, though, of blindly x-raying every ankle injury also adds up quickly, in dollars and exposure to radiation. In Ontario, x-raying every injury versus being more selective, could cost upwards of $730,000 per 100,000 patients seen. Therefore, over 20 years ago, a group of ER docs in Ottawa came up with a set of rules to decide when someone should get an x-ray, versus knowing nothing would be broken clinically. This ground breaking study, led to the Ottawa Ankle Rules, and is an extremely useful guide for the patient trying to decide when it is necessary to get assessed.

Basically, the rules are as follows.

• You should have an xray if you CAN NOT transfer weight to the injured ankle/foot TWICE, either immediately, OR in the ER.
• You should have an xray if you have TENDERNESS over the POSTERIOR (back part) of the EITHER malleolus (ankle bone).
• You should have an xray if you have TENDERNESS at the BASE of the 5th Metatarsal (baby digit), or the Navicular (bone on the instep of the foot).

That's it. If you CAN walk on the foot, no matter how sore, AND there is NO tenderness over any of the bones listed above, you can skip the x-ray. Get ice on it, keep it elevated, and give it some time.

Having said all that, of course, if things aren't settling over the next few days, get it looked at. 

These rules have been HIGHLY validated, and virtually 100% sensitive. They have gone a long way to cost savings for the health system, and have saved many unnecessary xrays.

Here's hoping Jeter is back in full form next year!