This document discusses mallet finger injuries, which involve disruption of the extensor tendon mechanism at the distal interphalangeal joint. It covers the anatomy of the finger extensor mechanism, classification of mallet finger injuries, clinical evaluation, treatment options including nonsurgical management with splinting and surgical repair or fixation, and management approaches for different types of acute mallet finger injuries.
Bicipital tendonitis is inflammation of long head of the biceps tendon under the bicipital groove.
In early stage, tendon becomes red and swollen, as tendonitis develops the tendon sheath can thicken.
In late stage, often become dark red in color due to inflammation.
As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially.
I hope this helps. :)
The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation.
I do not own any content.
Bicipital tendonitis is inflammation of long head of the biceps tendon under the bicipital groove.
In early stage, tendon becomes red and swollen, as tendonitis develops the tendon sheath can thicken.
In late stage, often become dark red in color due to inflammation.
As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially.
I hope this helps. :)
The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation.
I do not own any content.
After completion of this session, students should be able to discuss, identify, and describe:
The anatomical factors predisposing to the etiology of a fracture or dislocation.
The anatomy of displacement or deformity.
Imaging anatomy features and how to differentiate from epiphyseal lines.
Anatomy related to correct relocation and alignment.
Anatomical complications of a fracture or dislocation.
Hand splinting in common orthopedic & neurological condition 1POLY GHOSH
This Presentation is about role of splinting in orthopedic condition and neurological condition. This presentation can be benefitted for Orthotist, Occupational therapist, phyiotherapist and Physical medicine and rehabilitation specialist.
1.Anatomy
a.Course
b.Motor distribution
c.Sensory distribution
2.Common sites affected
3.Level of median nerve injury
4.Clinical feature with various test performed
5.Various syndromes related to median nerve
6.Treatment
7.Summary
The effect of intact fibula on functional outcome of reamed intramedullary in...Love2jaipal
detailed journal club presentation on The effect of intact fibula on functional outcome of reamed intramedullary interlocking nail in open and closed isolated tibial shaft fractures
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
3. Anatomy
• The extrinsic extensor tendon:
– Originates in the forearm.
– Courses over the MCP joint.
– Has an indirect attachment to
the proximal phalanx.
• The primary extensor force across
the MCP joint is transmitted
through the sagittal band
connections to the volar plate.
– The tendon trifurcates over the
proximal phalanx.
4. Anatomy
• Central slip:
– The central continuation of
the extensor tendon.
– Attaches to the dorsal base
of middle phalanx.
– Exerts an extensor force
across the PIP joint.
5. Anatomy
• Interossei and lumbricals:
– Provide the intrinsic contribution
to extensor mechanism.
– Form a lateral band on each side
of the digit, passing volar to the
MCP joint.
– The lateral bands join with the
lateral slips of the extrinsic
extensor tendon at the level of
PIP joint to form the conjoined
lateral bands.
– The two conjoined lateral bands
then converge dorsally and insert
at the base of the distal phalanx
as the terminal extensor tendon.
6. Anatomy
• The other components of the extensor
apparatus stabilize the extensor hood and
coordinate joint movement.
7. Anatomy
• Triangular Ligament:
– A thin tissue connecting the
conjoined lateral bands over the
middle phalanx.
– Prevents separation and volar
migration of the lateral bands when
the PIP joint is flexed.
8. Anatomy
• Transverse Retinacular Ligaments:
– Originate from each side of the PIP joint volar
plate.
– Insert dorsally into the adjacent conjoined
lateral band.
– Stabilize and limit dorsal migration of the
lateral bands during PIP joint extension.
9. Anatomy
• Oblique Retinacular Ligaments:
– Arise from the flexor tendon sheath and volar
aspect of the proximal phalanx.
– Course distally to insert onto the dorsal base
of the distal phalanx with the terminal
extensor tendon, thus linking and coordinating
PIP and DIP joint motion.
10. Mallet Finger
• An injury that
involves disruption of
the extensor
mechanism at the
level of the distal
interphalangeal (DIP)
joint.
12. Epidemiology
• Usually occurs in work environment or
during sports participation.
• Most frequently involved digits: long, ring,
and small fingers of the dominant hand.
• Age and Sex:
– Often seen in young to middle-aged males.
– Women with this injury tend to be older.
13. Genetic Predisposition
• Most mallet fingers are caused by a traumatic
event.
• However, Jones and Peterson found an
unusually high incidence in a three-generation
family, with 85% of the lesions developing
spontaneously or after minimal trauma.
• The authors proposed a possible genetic
predisposition toward mallet finger deformity in
certain individuals.
14.
15. Mechanism of Injury
• Most common
mechanism:
– Sudden forced flexion of
the extended fingertip.
– This results in either:
• stretching or tearing of
extensor tendon substance
or
• avulsion of tendon insertion
from the dorsum of distal
phalanx, with or without a
fragment of bone.
16. Mechanism of Injury
• Less frequent mechanism:
– Forced hyperextension of the DIP joint.
– This causes fracture at the dorsal base of the
distal phalanx.
• Open injuries are caused by a laceration,
crush, or deep abrasion.
17. Pathoanatomy
• A well-balanced system exists
between intrinsic and extrinsic
tendons, and between flexion and
extension forces across each finger
interphalangeal (IP) joint.
18. Pathoanatomy
• Any injury causing a flexion or extension
deformity in one IP joint can lead to tendon
imbalance, creating an opposite deformity in the
adjacent IP joint.
– At DIP joint: FDP flexion force is counterbalanced by
the terminal extensor tendon.
– At PIP joint: flexion forces of the FDP and FDS
tendons are counterbalanced by the extension forces
of the conjoined lateral bands and the central slip of
extensor apparatus.
19. Balance between flexion and extension
forces at the finger joints
The single dots represent the axes of flexion-extension
at each joint.
The double dots represent the areas of action of the
corresponding tendons at each joint.
20. Pathoanatomy
• With a mallet injury, the delicate balance
between flexion and extension forces is
disrupted.
• The following sequence of events occurs:
– Discontinuity of the terminal extensor tendon
– Migration of extensor apparatus proximally
– Increased extensor tone at PIP relative to DIP joint.
– Early or late swan neck deformity (hyperextension
of PIP joint with concomitant flexion of DIP joint) can
occur.
21. Classification
Acute vs. Chronic
• Acute mallet deformities = those
occurring within 4 weeks of injury.
• Chronic deformities = those presenting
later than 4 weeks from injury.
23. Classification
Doyle Classification
• Type I: Closed injury, with or
without a small avulsion fracture
at the dorsal base of distal
phalanx.
• Type II: open tendon injuries
caused by laceration at or around
the DIP joint.
• Type III: also open injuries; they
occur from a deep soft-tissue
abrasion with loss of skin and
tendon substance.
• Type IV: mallet fractures
24. Classification
Subclassifications of Type IV Injuries
• Damron & Engber:
– IVA: Distal phalanx physeal injuries in children.
– IVB: Distal phalanx fractures in adults involving 20%-
50% of the joint surface.
– IVC:
• Hyperextension injuries, resulting in a fracture fragment
>50% of the distal phalanx articular surface.
• Associated with DIP joint volar subluxation.
• Wehbé & Schneider:
– Subclassification based on fracture size and presence
or absence of DIP joint subluxation.
25. Clinical Evaluation
• Recognition and diagnosis of a mallet
finger are relatively straightforward.
• Patients present with pain, deformity,
and/or difficulty using the affected finger.
26. Clinical Evaluation
• Inspection:
– Soft tissues
– Deformity:
• Most patients develop an extensor lag
at the DIP joint immediately after injury.
• The deformity may be delayed by a few
hours or even days.
• Concurrent hyperextension of the PIP
joint (ie, swan neck posture) may be
noted with active finger extension.
27. Clinical Evaluation
• Palpation:
– Tenderness can be elicited in acute injuries
with palpation over the dorsal margin of DIP
joint.
• ROM:
– Measure finger MCP and PIP joint motion.
28. Radiographic Evaluation
• Posteroanterior, oblique, and
lateral radiographs of the digit
are recommended to assess
for bone injury and joint
alignment.
29. Neglected Injuries
• Neglecting mallet injury often results in
permanent stiffness and deformity at the
DIP joint level.
30. Treatment Options
• Non-surgical:
–Successful in most mallet injuries.
• Surgical:
–Treatment of either an acute or a
chronic mallet finger
–Salvage of failed prior treatment
31. Treatment Options
• Many splint configurations and surgical
techniques have been described over the
last century.
• However, the optimal treatment of each
type of mallet finger injury remains
controversial.
32. Definition of satisfactory outcome
(Geyman et al.)
• DIP joint exhibits a residual extensor lag
≤20°
• DIP flexion arc is ≥50°
• Patient reports minimal or no pain.
33. Management of Acute Mallet Finger Injuries
Nonsurgical
• Indications:
–Type I mallet injuries
– Closed mallet fractures involving less
than one third of the articular surface
with no associated DIP joint subluxation.
34. Management of Acute Mallet Finger Injuries
Nonsurgical
• Outcome:
– About 80% of closed injuries will heal with 6
(tendinous)—8 (bony) weeks of splintage with a
further 2 weeks at night.
– If the tendon does not heal within this period of time
further splintage can be successful.
– If this fails, open repair may be considered.
– Controversy exist regarding:
• style of splint
• duration of immobilization necessary for acceptable outcome
35. Management of Acute Mallet Finger Injuries
Nonsurgical
• Immobilization of both PIP and
DIP joints was previously
thought to be necessary to
relax the extensor hood and
intrinsic musculature during
terminal extensor tendon
healing.
• However, Katzman et al
demonstrated that only the DIP
joint need be immobilized in
extension to allow healing of
the mallet injury.
36. Management of Acute Mallet Finger Injuries
Nonsurgical
• Most authors currently advocate
immobilization of the DIP joint alone.
• In the presence of a swan neck
deformity, however, temporary
inclusion of the PIP joint in flexion
has been suggested.
• Combined PIP and DIP joint splinting
has not been conclusively proved to
restore tendon balance in a swan
neck deformity.
37. Management of Acute Mallet Finger Injuries
Nonsurgical
Splinting
• Numerous splints have
been devised for managing
mallet finger injuries.
• Common examples:
– The stack splint
– The perforated thermoplastic
splint
– The aluminum foam splint
39. Three different mallet finger splints
A, Stack splint (Stax Finger Splint, Sammons Preston Rolyan, Bolingbrook, IL)
B, Perforated thermoplastic splint (Aquaplast Splinting Material, Sammons Preston
Rolyan)
C, Aluminum foam splint
40. Management of Acute Mallet Finger Injuries
Nonsurgical
Splinting
• ‘Mexican hat’ splint:
– Incorporates a “buckle” over the DIP joint to
alleviate undue pressure on the healing
terminal extensor tendon.
• A sterilized aluminum splint secured with
sterile tape strips has been proposed to
treat mallet injuries in operating room
personnel.
41. Management of Acute Mallet Finger Injuries
Nonsurgical
Splinting
• Many splints, same treatment
principles:
– The digit is immobilized in full extension
or slight hyperextension across the DIP
joint.
– Avoid excessive extension because
dorsal skin vascular compromise can
occur when the joint is immobilized in >
50% of the normal range for passive DIP
joint hyperextension.
42. Management of Acute Mallet Finger Injuries
Nonsurgical
Splinting
• Instruct the patient on how to change the
splint for periodic cleaning and
examination of the skin without allowing
the DIP joint to flex.
– Continuous immobilization: 6-8 weeks.
– Nighttime splinting: 2 weeks.
• A new full-length course of immobilization
is recommended when the DIP joint is
inadvertently flexed during treatment.
43. Management of Acute Mallet Finger Injuries
Nonsurgical
Splinting
• Requirements for
successful splinting:
– Frequent physician
assessment (check films in
the splint over the first 2
weeks)
– Patient compliance
44. Management of Acute Mallet Finger Injuries
Nonsurgical
Splinting
• A small residual extensor lag and
radiographic evidence of DIP joint
osteoarthritis do not preclude a successful
treatment result.
45. Management of Acute Mallet Finger Injuries
Nonsurgical
Casting
• Infrequently used technique.
• May be beneficial in:
– Children
– patients deemed noncompliant with splint treatment
• Described by Smillie (1937) for acute mallet
finger injuries.
• Both IP joints are casted:
– PIP joint in 60° of flexion
– DIP joint in slight hyperextension
• Inclusion of PIP joint in flexion prevents a tubular
cast from inadvertently falling off the finger.
46. Management of Acute Mallet Finger Injuries
Surgical
Type I Injury
• Splinting is the treatment of choice.
• Surgical indications:
– Individuals unable to comply with a splinting
regimen
– Patients who would have difficulty performing
their jobs with an external splint (eg,
surgeons, dentists, musicians).
47. Management of Acute Mallet Finger Injuries
Surgical
Type I Injury
• To immobilize the DIP joint in
extension, a transarticular K-wire
is driven longitudinally or
obliquely across the DIP joint.
– The tip of the wire is buried in the
middle phalanx.
– The distal end is either capped or
cut beneath the skin surface.
• Post-Operatively:
– K-wire is removed after 6-8 weeks.
– This is followed by 2 weeks of
nighttime extension splinting.
48. Management of Acute Mallet Finger Injuries
Surgical
Open Injuries (Types II and III)
• Open mallet injuries require surgical
repair.
• Various surgical methods have been
described.
49. Management of Acute Mallet Finger Injuries
Surgical
Open Injuries (Types II and III)
• The tendon can be repaired separately from the
skin.
• However, as there is little subcutaneous tissue:
– The repair material may be superficial
– Successful results have been achieved with a mass
repair of tendon and skin.
• A K-wire through the DIP joint is useful to
stabilise the repair while the tendon heals.
• If the tendon ends are damaged a turndown of
one lateral band can be used to strengthen the
repair.
– This method may also be useful for chronic mallet
injuries.
50. Management of Acute Mallet Finger Injuries
Surgical
Open Injuries (Types II and III)
• Doyle:
– A combination of surgical repair and splinting
for acute tendon lacerations overlying the DIP
joint.
– A running suture is used to reapproximate
both skin and tendon, followed by application
of an extension splint.
– The suture is removed after 10-12 days.
– Splinting is continued for 6 weeks.
51. Management of Acute Mallet Finger Injuries
Surgical
Open Injuries (Types II and III)
• Type III mallet deformities:
– Involve loss of skin, subcutaneous tissues, and
tendon substance.
– Caused by deep abrasions, crush injuries, and
degloving accidents.
– Often difficult to treat because of exposure of both
bone and articular cartilage.
– Staged reconstructive surgery may be considered:
• Early skin coverage is followed by restoration of extensor
tendon function with insertion of a free tendon graft.
– In severe cases, DIP arthrodesis with bone shortening
or fingertip amputation may be more appropriate.
52. Management of Acute Mallet Finger Injuries
Surgical
Mallet Fracture (Type IV)
• Management strategies for the different
subtypes of mallet fractures remain
controversial.
• Treatment alternatives:
– Observation with reassurance
– Extension splinting
– Closed and open reduction with internal
fixation
– DIP joint arthrodesis.
53. Management of Acute Mallet Finger Injuries
Surgical
Mallet Fracture (Type IV)
• A true lateral radiograph of the injured digit is valuable
for determining:
– size and displacement of fracture fragment
– presence or absence of volar subluxation of the distal phalanx.
• Closed mallet fracture injuries involving less than one
third of the articular surface and without DIP joint
subluxation can be reliably treated with extension
splinting alone.
• Wehbé & Schneider and Schneider advocated
nonsurgical management of nearly all mallet fractures,
regardless of the size or displacement of the fracture
fragment or the presence of volar subluxation of the
distal phalanx.
54. Calculations for determining fracture fragment size, fragment
displacement, and distal interphalangeal joint subluxation.
A and B = the length of the involved bone segments at the articular surface of
the distal phalanx, C = the amount of fracture fragment displacement, D = the
distance between the midaxial lines of the middle and distal phalanges.
55. Management of Acute Mallet Finger Injuries
Surgical
Mallet Fracture (Type IV)
• Disadvantages of surgical treatment of
mallet fractures:
– Technically demanding
– Higher complication rate than nonsurgical
management
• A dorsal prominence overlying the DIP
joint may follow nonsurgical treatment.
– This same deformity is seen in the surgically
treated patients.
56. Lateral radiograph of a remodeled
mallet fracture
The arrows indicate the old fracture line.
The distal interphalangeal joint remains congruent.
57. Management of Acute Mallet Finger Injuries
Surgical
Mallet Fracture (Type IV)
• Indications for surgical intervention:
–Mallet fractures involving more than one
third of articular surface
– Fractures with associated DIP joint
subluxation
58. Management of Acute Mallet Finger Injuries
Surgical
Mallet Fracture (Type IV)
• Techniques:
– Transarticular pinning of DIP joint ±
fracture fragment fixation
– Tension band constructs
– Compression pinning
– Extension block pinning
• All of these techniques involve
placement of at least one K-wire to
immobilize the DIP joint in
extension.
59. Extension
block pinning
technique
A, With the distal phalanx
extended, a K-wire is
inserted proximal to the
fractured fragment.
B, The fracture is reduced
manually by directing the
exposed end of the K-wire
distally.
C, The wire is drilled into
the head of the middle
phalanx, and a second wire
is passed retrograde
across the distal
interphalangeal joint.
60. Management of Acute Mallet Finger Injuries
Surgical
Mallet Fracture (Type IV)
• Open vs. Closed Reduction:
– Proponents of open reduction think that associated
complications can be minimized by using meticulous
surgical technique.
– Closed reduction with percutaneous pinning has been
advocated by surgeons who are concerned about
complications with open management.
– They cite problems related to reducing the small
articular fragment, the inability to accurately assess
DIP joint congruency, and the potential for injury to
the tenuous soft-tissue envelope.
61. Management of Chronic Mallet Finger
Injuries
• Patients who present for treatment > 4
weeks after injury typically report pain,
dissatisfaction with the appearance of the
digit, and interference with use of the
finger for normal work and recreational
activities.
• As with acute mallet injuries, both
nonsurgical and surgical treatment
measures have been advocated.
62. Management of Chronic Mallet Finger Injuries
Nonsurgical
• Continuous extension splinting (10 weeks)
should be considered as an alternative to
surgery for a chronic mallet finger
deformity (Patel et al., 1986).
63. Management of Chronic Mallet Finger Injuries
Nonsurgical
• Garberman et al found no differences in
outcome between patients splinted early (<2
weeks after injury) and late (>4 weeks after
injury).
• They recommended DIP joint extension splinting
for closed mallet injuries regardless of chronicity,
including fractures involving less than one third
of the joint surface.
• Brzezienski and Schneider advocated splinting
for all chronic mallet deformities resulting from
either neglect or previous failed treatment.
64. Management of Chronic Mallet Finger Injuries
Surgical
• Rationale of surgery:
– Chronic mallet finger may develop pathologic
features that interfere with treatment results.
– A static contracture of the extensor
mechanism can develop over time, making it
difficult to achieve apposition of the tendon
ends with simple extension splinting.
65. Management of Chronic Mallet Finger Injuries
Surgical
Surgical procedures for chronic mallet finger:
• Aims:
– to stabilize the DIP joint
– to improve active DIP joint extension.
• Examples:
– Terminal extensor tendon shortening
– Tenodermodesis
– Oblique retinacular ligament reconstruction
– Fowler’s central slip tenotomy
66. Management of Chronic Mallet Finger Injuries
Surgical
• The abbreviato operation (Lind & Hansen, 1989):
– The extensor tendon is transected near the DIP joint
and repaired directly, without overlapping and without
excision of damaged tendon tissue.
– Scar contraction at the repair site is thought to correct
the flexion deformity.
– A transarticular pin is used to immobilize the DIP joint
in extension for 6 weeks.
– Timing:
• The authors recommended performing the procedure within
3 months of injury in patients with marked ligamentous laxity
to avoid progression to a swan neck deformity.
• However, the procedure is not recommended before 6
months to allow potential spontaneous correction of the
extensor lag.
67. Management of Chronic Mallet Finger Injuries
Surgical
• Tenodermodesis:
– Originally described by Iselin et al.
– Used to manage chronic mallet finger
deformities in both adults and
children.
– Technique:
• An elliptical wedge of skin, tendon, and
scar tissue is resected.
• The skin and tendon are reapproximated
as a single unit with sutures.
• Similar to the abbreviato operation, a
temporary K-wire is used to maintain the
DIP joint in full extension during the
healing process.
68. Tenodermodesis Procedure
In the tenodermodesis
procedure, a 3- to 4-
mm elliptical wedge of
skin, subcutaneous
tissue, and tendon/scar
is resected.
A, The full-thickness
defect is repaired with
nonabsorbable sutures.
B, Before securing the
sutures, the distal
interphalangeal joint is
immobilized in
extension with a
Kirschner wire.
69. Management of Chronic Mallet Finger Injuries
Surgical
• Spiral Oblique Retinacular Ligament Reconstruction:
– Originally reported by Thompson et al; later modified by
Kleinman and Petersen.
– Addresses the imbalance of flexion and extension forces
contributing to a chronic mallet deformity.
– Restores the dynamic tenodesis effect of the oblique retinacular
ligaments in coordinating PIP and DIP joint extension.
– A free tendon graft is harvested and secured distally to the
dorsal base of distal phalanx.
– The graft is passed volarward in a spiral fashion around the
radial aspect of the middle phalanx and is secured proximally to
the ulnar side of the flexor tendon sheath at the level of the
proximal phalanx or directly to bone.
– The PIP and DIP joints are temporarily immobilized with K-wires
before initiating finger motion exercises.
70. Spiral oblique retinacular ligament reconstruction
A, Lateral view. The tendon graft is secured to the dorsum of the distal phalanx with a
pullout suture or wire. The graft is passed along the radial border of the middle phalanx,
deep to the neurovascular bundle and volar to the flexor tendon sheath.
B, Volar view. The graft is then sutured to the ulnar edge of the flexor tendon sheath at
the level of the proximal phalanx.
71. Management of Chronic Mallet Finger Injuries
Surgical
• Fowler’s Central Slip Tenotomy:
– Aim: To correct for increased extensor tone at the PIP
joint resulting from retraction of the extensor
apparatus.
– Timing:
• The operation should be delayed until at least 3 months after
injury to allow restoration of terminal extensor tendon
continuity by scar tissue (Houpt et al, 1993).
– To prevent boutonnière deformity, the triangular
ligament bridging the two conjoined lateral bands
must be preserved when cutting the extensor
mechanism.
– Unlike the other corrective procedures, active finger
motion is permitted immediately after surgery.
72. Dorsal (A) and lateral (B) views of
Fowler’s central slip tenotomy. The
central slip is transected immediately
proximal to its insertion on the base of
the middle phalanx. The lateral bands
and triangular ligament are preserved.
73. Management of Chronic Mallet Finger Injuries
Surgical
• DIP Joint Arthrodesis:
– Indications: Salvage procedure for patients with
painful mallet finger injuries secondary to arthritis,
deformity, infection, and/or failed prior surgery.
– Can be effectively performed with K-wires, tension
band wiring, or IM screw fixation.
– Position of fusion: between neutral and 10° of flexion.
– Advantages of arthrodesis:
• Reliable pain relief
• Early PIP joint finger motion
74. Posteroanterior (A)
and lateral (B)
radiographs of a DIP
joint arthrodesis.
Fixation was achieved
with a headless
differential-pitch
compression screw.
75. Complications
• Complication rates:
– In digits treated with extension splinting: 45%
– In digits treated surgically: 53%.
76. Complications
• Complications associated with splinting:
– Most are transient.
– Most resolve with adjustment of the splint or
after completion of treatment.
– Complications include:
• Skin maceration and ulceration
• Tape allergy
• Transverse nail plate grooves
• Splint-related pain
78. Mallet Thumb
• Unlike mallet finger, avulsion of
the extensor pollicis longus
(EPL) tendon at its distal
insertion (mallet thumb) is rare.
• Although the recommended
treatment for closed mallet
finger is conservative, some
authors proposed operative
treatment for mallet thumb.
79. References
• Bendre AA, Hartigan BJ, Kalainov DM: Mallet
Finger. J Am Acad Orthop Surg 2005;13:336-
344
• Dean BJF, Little C: Fractures of the
metacarpals and phalanges. Orthopaedics &
Trauma 2011; 25(1):43-56
• De Smet L, van Ransbeeck H: Mallet Thumb.
Acta Orthopædica Belgica 2003; 69(1): 77-78
• Rust PA, Eckersley R: Twenty questions on
tendon injuries in the hand. Current
Orthopaedics (2008) 22, 17–24
Editor's Notes
Lateral radiographs of the middle finger showing mallet fracture with dorsally displaced intra-articular fracture fragment from the base of the distal phalanx involving about 50 % of the articular surface without comminution and volar subluxation of the distal phalanx.
Lateral radiograph demonstrating a bony mallet injury, note the extensor lag of the distal interphalangeal joint.
A thermoplastic mallet splint (Stack)
Lateral radiograph of a bony mallet injury treated with a mallet splint, this radiograph confirms a satisfactory reduction with a fully extended joint.
Patel MR, Desai SS, Bassini-Lipson L: Conservative management of chronic mallet finger. J Hand Surg [Am] 1986; 11:570-573.