The guidelines presented by the New York State Workers Compensation Board offer fundamental principles for addressing Mallet Finger. These directives are designed to assist healthcare professionals in identifying suitable therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in managing Mallet Finger can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most appropriate therapeutic methods for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The final decision regarding the management of Mallet Finger should entail collaboration between the patient and their healthcare provider.
Mallet Finger
Mallet finger is a common occupational injury, although it may occur with minimal apparent trauma. This injury involves the rupture of the extensor mechanism of a digit at the distal upper extremity joint, with or without a fracture of the distal phalangeal segment. Diagnosis is typically based on the inability to extend the distal interphalangeal joint, usually following trauma or distal interphalangeal joint arthrosis.
Diagnostic Studies
X-Rays – Recommended in most cases of mallet finger to determine the presence of a fracture. The evidence supports the use of X-rays for this purpose. Ultrasound – Not recommended for diagnosing mallet finger.
Medications
For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Acetaminophen (or the analog paracetamol) may be a reasonable alternative to NSAIDs for patients who are not candidates for NSAIDs, although most evidence suggests acetaminophen is modestly less effective.
NSAIDs, including over-the-counter agents, are recommended for the treatment of acute, subacute, or chronic mallet finger. The frequency and duration of NSAID use may vary for different patients, with indications for discontinuation being the resolution of symptoms, lack of efficacy, or the development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concomitant use of cytoprotective classes of drugs (misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors) for patients at high risk of gastrointestinal bleeding. Indications, frequency, dose, and duration are specified based on the patient’s risk profile. Intolerance, adverse effects, or discontinuation of NSAID are indications for discontinuation.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should discuss the risks and benefits of NSAID therapy for pain. Acetaminophen or aspirin is recommended as the first-line therapy, appearing to be the safest regarding cardiovascular adverse effects. If needed, non-selective NSAIDs are preferred over COX-2 specific drugs. For patients receiving low-dose aspirin for cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen for Treatment of Mallet Finger Pain
Recommended for the treatment of mallet finger pain, especially in patients with contraindications for NSAIDs. All patients with mallet finger pain, including acute, subacute, chronic, and post-operative, are included as indications. Dose, frequency, and indications for discontinuation are provided.
Opioids for Treatment of Acute, Subacute, or Chronic Mallet Finger Pain
Not recommended for the treatment of acute, subacute, or chronic mallet finger pain. Recommended for limited use (not more than seven days) for postoperative pain management as adjunctive therapy to more effective treatments. Prescribed as needed, with a rationale for recommendation provided.
Rehabilitation
Therapy: Active Therapeutic Exercise
- Not Recommended: Acutely, most patients with mallet finger do not require participation in an exercise program.
- Recommended: In select patients with residual deficits, particularly post-operatively.
- Frequency/Dose/Duration: Total numbers of visits may range from as few as two to three for patients with mild functional deficits, up to 12 to 15 for more severe deficits with documentation of ongoing objective functional improvement. If ongoing deficits persist, more than 12 to 15 visits may be indicated with documentation of functional improvement towards specific goals. As part of the rehabilitation plan, a home exercise program should be developed and performed in conjunction with therapy.
Therapy: Passive Splints – Extension Splinting With the Joint in a Neutral Position
- Recommended: For the treatment of acute or subacute mallet finger.
- Indications: Acute or subacute mallet finger.
- Frequency/Duration: Splinting for six to eight weeks, with possible nocturnal use for an additional two to four weeks. Splints must hold the finger in continuous, full extension for a minimum duration of six weeks. Some protocols involve eight weeks, while others involve nocturnal use for an additional two to four weeks.
- Evidence for the Use of Splints
Instructions for Splint Wear
- Recommended: That careful instructions on splint wear be provided to patients.
- Evidence for the Use of Splint Wear
Surgery
- Not Recommended: In general.
- Recommended: In select patients with displaced fractures when the DIP joint is subluxed.
