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Complicated Mallets
795 Plays1 year ago
Josh and Miranda talk about complicated mallets and the treatment options.
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Transcript
Introduction and Topic Overview
00:00:07
Speaker
I'm Josh McDonald and I'm random material and we are hand therapy Academy. We're going to talk today about complicated mallet injuries. You know, we talked in the past about what kind of splints to make and how to deal when they first come in, but sometimes things don't go so well and we don't always get them until things have gone poorly. So what do you do with that patient who just has this nagging lag and they're not happy
Understanding Patient Goals and Expectations
00:00:31
Speaker
with it? You know, positive.
00:00:32
Speaker
Acceptable outcomes are five to eight degrees short of full extension. What if they're 20? What do you do? What's your go-to? So Miranda, what do you think? If you have a patient come in and they've got this long standing thing, what's your response?
00:00:45
Speaker
Yeah, my first thing is to find out what their goals are, right? Because 20 degree lag to some people might not be a big deal, right? So I think first is identifying the goal. And I'm guessing in this case, where it's your patient, it's their goal because they're returning to seek or they're seeking out more treatment for them. And I think a lot of it is
00:01:04
Speaker
you know, are they gonna get much better? Is there gonna keep, you know, is the tendon a little bit attenuated? How long did they wear the split before before? Is it a bony mallet? Is it a soft tissue mallet? So those are the questions I'm wondering and asking at the same time.
Tendon Problems and Treatment Options
00:01:19
Speaker
Yeah. I start wondering if it's attenuated or is it ruptured, whether it's an avulsion or a rupture of the tendon, because if you lose terminal tendons insertion on the extensor tendon side, then FDP on the flexor side is unchecked. And so it will begin to pull down into a contracture. And I've had doctors refer someone to me and say, hey, this patient, they suffered a mallet injury.
00:01:45
Speaker
weeks and weeks and weeks ago and are just now coming in and it's stuck. It is stuck into flexion. And so then we've got to start looking at like a serial progressive splinting plan to try to get that to relax and not get stuck in a joint contracture with molder plate issues and all that.
00:02:02
Speaker
And then maybe they look at doing something about a surgery later but yes sometimes that becomes a complicated factor yeah and then how long so if they're really attenuated like that do you start the tendon protocol over using okay we're gonna do another six to eight weeks of a mobilization.
00:02:17
Speaker
If they have not had any intervention yet and they haven't already tried that, then I feel like it doesn't hurt to try it as long as they can be compliant and they're on board with it. Like if I introduce them like, yeah, let's do it, then I feel like it doesn't hurt. If it's someone who's already been through that and it was unsuccessful, then I'm much more leery about initiating that because we just beat in the same drum.
Mallet Injuries in Older Patients: To Fuse or Not?
00:02:40
Speaker
Right? And then, like I said, the age of the patient, you know, is this like osteoarthritic changes, right? So a lot of times there are some of our older patients or even those that have had injuries, they have joint changes and they're already going to have a leg regardless of the status of that terminal tendon.
00:02:56
Speaker
Yeah yeah and i've had doctors give patients the options of you know if you're not happy with it we confuse it we can well i think okay what position do you fuse it in typically a functional dip position for fusion is round about twenty to thirty degrees if that's what you're lagging too. But you still have flexion activation beyond that.
00:03:18
Speaker
then why would I put it at just 20 to 30? And that's all you ever have. At least you got some functional movements. So I'm a little leery to fuse it unless it is truly flexion contracted. Yeah, you probably just leave it, I would think. And then I think another complication, this isn't the case with yours, is where they end up with a swan neck.
Swan Neck Issues: Origins and Solutions
00:03:38
Speaker
Yeah, then you're chasing your tail a little bit. That gets tricky. What is your response on a swan neck like that?
00:03:45
Speaker
Usually, I think that it's a secondary problem for the mallet, right? Those bands have started drooping down voluntarily because there's not enough tension on them, then I might, or excuse me, going dorsally, I said, voluntarily. But if those lateral bands are going dorsally, then I'm thinking, well, is that because they've had an unchecked mallet for a while? And so the natural migration of the bands is going up.
00:04:10
Speaker
So if I'm thinking it's that, then I think, well, if I correct the mallet, then a lot of times I think the swan neck will correct itself and I have seen it correct itself. But if it's a more severe case and it's been going on longer than I would say a few months, then I'm going to probably do something at the PIP joint as well. So I'm going to extend the DIP and flex the PIP and hold them there.
00:04:35
Speaker
And depending on how progressed the swan neck is, that can be quite a bit of time to reorient and re-centralize those lateral bands. If they've really collapsed dorsally, it can be quite a bit to get those to repair, and it may be just something they wear a functional splint for the foreseeable future just to prevent that joint collapse and a longer-term problem.
00:04:56
Speaker
Right. Because we know if swan necks progress too far, then you lose flexion, right? You're not able to flex in the PIP anymore. And that's a huge functional limitation. So I think we really want to make sure we address that right away. But making a splint that corrects a mallet and a PIP hyperextended is, I think, not always easy. It is tricky.
Splint Challenges and Corrections
00:05:17
Speaker
It is complicated. And it's something I usually reserve for those patients where it's
00:05:22
Speaker
It's obviously not bilateral. Like some patients come in and they just hyperextended the PIPs and that's just their resting. So I'll look at the other side. Okay, maybe it matches. It's not my job to fix what's their normal anatomy. I tried not to chase that because that split is a complicated one to make for sure.
00:05:39
Speaker
Yeah. And I think a lot of times you can do a mallet with an overlay or a silver ring, um, or there's some cheaper silver ring options you can get. You don't have to spend the 110, right? I think we've found those like knockoff ones that are 20, $25, which seems like a more feasible option than the silver rings, which you're not going to, because you're not, hopefully you're not going to need the splint longterm. Hopefully you need it, you know, three, three months or so.
00:06:03
Speaker
Yeah, and I find that one piece splint that is for both dip extension and pip flexion to counteract the swan neck is hard to put on while following mallet precautions. It's almost not possible to put on by yourself one handed.
00:06:20
Speaker
It's a very tricky thing to keep that in extension of the DIP while sliding it on. It is just fraught with potential for that DIP to collapse down while you're putting it on. So I don't use it for the acute patient unless it's a huge necessity because they've collapsed significantly at the PIP. Yeah. I think it's a complicated problem we want to be aware of, make sure it's not getting worse. But I also think oftentimes if you correct the initial etiology of the problem, you're going to fix the swan neck.
00:06:48
Speaker
Yeah, yeah, for sure.
Case Study: Limits and Fusion Decisions
00:06:50
Speaker
Yeah, I've got a patient now who was pinned for eight weeks, came out of the pin and instantly dropped back down. And the doctor said, well, let's just send you to therapy and see what they can do. And she comes in.
00:07:02
Speaker
maybe not so compliant with everything, comes in with a 20 degree lag, leaves after some work to activate and work on tightening that EDC up a little bit and leaves at like a minus 9, minus 11 somewhere in there, comes back the next visit and is a little bit more droopy. And so are we chasing our tails or would she be getting worse?
00:07:22
Speaker
if she were seeing us kind of resetting each time so it's a tough one to know like she wants to keep trying for a while so we've kind of set a marker let's try for this match and then we'll try for this many weeks and we're kind of setting some realistic expectations but some specific time frames to to measure our progress by yeah and then at what point are you telling her hey go back to it like how you know if it's getting that much worse how bad is it before you say you're going back to the doctor
00:07:48
Speaker
Yeah. And, and in this case, the doctor said, come back to me if you want a fusion. Okay. So yeah, it was, uh, even if it gets way worse, you're still. Yeah. Yeah. So the doctor's thought process, and I don't disagree with this. The doctor's thought process was you've got a lag, but it's functional grip. If therapy can't fix it.
00:08:08
Speaker
and you want it fixed, the only tool she has left in her toolbox is fusion. So the patient then needs to decide if therapy didn't resolve it, does she want to live with it or do fusion? Because that's the only tool left in their toolbox after doing a pinning. And ultimately, you splint for long enough and they end up with an internal fusion. So you kind of create that. Yeah, that's
Risks of Long-Term Splinting
00:08:29
Speaker
a good point. And then you're also making changes to their motor cortex with prolonged splinting, right? So we're changing their brains a little bit too.
00:08:36
Speaker
Yeah. Skin integrity issues, all of that. So we don't want to do too long of splinting. You just end up causing more problems. If you're not making forward progress, you could be making complications. Yeah, definitely.
Listener Engagement and Questions
00:08:49
Speaker
Well, hopefully that's helpful. We don't necessarily have answers for all of the questions out there, but it's good just to have a discussion and to kind of hear some other people's perspectives on it. Let us know what you think in the comments, what you like to do for those chronic mallet fingers. And then if you have any questions, feel free to reach out to us through our email info at hand therapy Academy or any of our social media platforms, hand therapy Academy.