Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Mallet Finger
1.4k Plays2 years ago
Hand Therapists, Josh and Miranda cover mallet finger injuries. From boney to soft tissues injuries, we cover splinting and post splint therapy.
Recommended
Transcript
Introduction to Mallet Injuries
00:00:05
Speaker
Hi guys, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy. All right, today we are gonna be talking about mallet injuries, and we're gonna be talking about soft tissue versus bony, kind of what we do for them, how we splint them, and post splinting, what do we do? So Josh, what is your go-to for mallet splint? Say again, since the mallet splint, what type of splint are you making? Are you doing off the shelf? Are you doing custom?
00:00:33
Speaker
I'm doing custom, almost like I don't even have off the shelf splints in my clinic. I don't have the kind of stack splints. I feel like it's a one size fits nobody kind of approach. So we're making custom mallet finger splints. And I'll usually make our little like figure eight or it looks like an awareness ribbon.
Splint Stability Techniques
00:00:49
Speaker
I'll usually make that one, but there are times when I'll make a different type if there's like wounds or other complications. Even sometimes if it's a patient that's work or whatever, you have a hard time with that thing falling off, I may do some Kinesia tape and then make the splint over top of it.
00:01:03
Speaker
Very good. I know sometimes I'll do like a co-ban sandwich. You know, the thing about using co-ban or elastic wrap is you don't want to make it too tight, but I sometimes will put one wrap underneath the splint on and then another wrap on top. So then the co-ban kind of sticks the splint together because these are tricky, right? And if the splint comes off, they're even three weeks in and that splint comes off, then you're kind of restarting that protocol all over, which I think is kind of frustrating and scary for patients. They want to know that splint's going to stay on.
Treatment Outcomes and Preferences
00:01:31
Speaker
Yeah. And they can be really successful approach with that, but you have this expected tolerable 10 degree, I think is the current like a 10 degree lag is a, is a reasonable outcome by the time you get to the end of all this. If it were me, if I got a mallet finger, I think I might kind of choose pinning, like, you know, a little subtle K wire that maybe sticks out a little bit that I just have to kind of cover and protect and keep clean. Then I can't screw it up accidentally, like in the middle of the night or sticking my hand in my pocket, that kind of thing.
00:01:59
Speaker
Yeah, that's true. I think as, I don't know what I would choose. I kind of think I'd choose this point, but maybe I'm just kind of being argumentative. I don't know. So when we're talking about mallet fingers, there's two most common types. There's like four different total types, but two common ones. Uh, we've got a soft tissue and a bony mallet. Uh, maybe Miranda talk about the soft tissue and what kind of are some of our thought process that goes behind that type.
00:02:23
Speaker
Yeah, so the soft tissue mallets, those are where the tendon detaches, but it doesn't bring the bone with it. So I think these don't do quite as well as it would if it was a bony mallet. So we know with the bony mallet, if that bone has to re-adhere, it's usually a little bit easier. I think there's less chance of there being a bit of an extensor lag. So with the soft tissue ones, it's typically an immobilization for six to eight weeks.
00:02:51
Speaker
I'm telling the patients this is the date you're starting. If at any time this finger bends between now and the six weeks, you're starting that protocol over.
Patient Education on Splint Use
00:03:00
Speaker
And if they're older or maybe diabetic or they're a smoker, I know that they're going to heal slower and take longer to recover, then sometimes I'll tell them that you're going to be closer to the eight week mark because nothing's more frustrating than immobilizing your finger and then having it droop back down afterwards.
00:03:17
Speaker
Typically six to eight weeks, keeping it immobilized, showing them, I think this is where education is really key, showing them how to take it on and off without bending the tip of the finger, right? So you're usually placing your finger or high shoulder, put it on the table and keep that joint and extension and have the splint slide on and off. And then I think another key to educating them is making sure it stays dry, right? So it doesn't get macerated. So sometimes we'll give them a splint for in the shower and then they can come out and put a dry one on.
00:03:45
Speaker
And oftentimes I give them two splints anyways, because they're just such small pieces and they're so hard to get right. Like I think Mal is one of the hardest splints to make as a therapist, even though it seems relatively simple.
00:03:58
Speaker
Yeah, you're right. I'm always making two. The little figure eight style that we make is a quick enough fabrication that I'll make two. And I tell the patient because you're different and I'm different every moment. One of these is going to fit better. Pick that one is your all the time. And then the other one is your shower one. And then I'll say if you can find a quiet place to sit there for maybe 10 or 15 minutes after shower with that hand completely flat, then that's going to be your best way to make sure that doesn't get macerated and then put the daytime one back on again. Yeah. So same kind of thing. I'm always making two.
00:04:26
Speaker
because sometimes one is just gonna fit better than another, yeah.
Bony Mallet Injuries and Pinning Methods
00:04:30
Speaker
Yeah, it's always hard to make them exactly the same, right? Yeah. So let's talk bally, pony mallet for a minute. That one, a lot of times that's the one where you're gonna see K-wires. Sometimes you have these crossing XK wires. Sometimes you have just a pin through the back that kind of loops around when it comes out again. So you're more likely to see a K-wire for that bony fixation, that primary fixation.
00:04:53
Speaker
That one tends to come out a little bit better prognosis wise. It's just a matter of making something that protects that pin. So that's what I may make something like more of a stack style splint custom or a volar gutter and then just extend the end of it a little bit and kind of protect if the pin comes out a little bit. So that's where you may have to get a little more creative with your splintings if you've got pins coming out of a bony mallet.
00:05:14
Speaker
Yeah. And sometimes I know, like I worked with one hand surgeon, he would always bury the pen, you know, so, but still that tip would get so hypersensitive, you know, especially if the pen was starting to try to migrate out at all. But then later they have to go in and make a little small cut and, you know, retrieve the very pen. So I think there's pros and cons to having one that's buried versus not one being infection, right?
00:05:36
Speaker
Right.
DIP Joint Extension Best Practices
00:05:37
Speaker
Right. For sure. And just convenience of life, catching it on things, you know, you go to, you forget and you go to touch the dog and then you got to clean that whole thing again. Yeah. All that stuff. Right. Yeah, definitely. For those soft tissue mallets, um, let's talk about the angle of extension on that DIP joint. Um, used to be for a long time, it was max extension. And then we backed off from that in like 10 to 15 degrees. Where do we stand now on what's kind of best practice?
00:05:59
Speaker
Yeah. So when you're saying max extension, are you referring to hyper extension? Yes. Yes. Yes. I think when I started too, it was all about hyper extension and then something came out where they were saying if you hyper extended the digit too much, you created a vascularity issue. So if that joint was beyond neutral, then it didn't get as much blood flow. So then the theory was it didn't heal as well. So now they say, um,
00:06:24
Speaker
Put them just in neutral maybe a slight extension hyper extension but not too much and I think you need to look at your Patient or your client and assess them and if they have a lot of hypermobility Then you know putting them in some of those extreme angles is not anything that's different for them, right? Versus if you're forcing someone then you're definitely probably going to be compromising the blood flow so I always put them in neutral sometimes just like slight extension because I know when I'm splinting them and
00:06:49
Speaker
they often kind of rest into neutral then, right? So if I'm splinting them in five degrees hyperextension, then when the splint is actually put on and strapped in, it'll actually probably hold them right at neutral. And then check. Go ahead. Check in the contralateral side, just kind of seeing what their joint mobility looks like. And if I hyperextend 5, 10 or 15 or whatever, does it cause that blanching over that dorsal surface?
Managing Patient Expectations Post-Treatment
00:07:13
Speaker
And if it does in the contralateral, I'm probably not going to pursue that on the on the affected side.
00:07:17
Speaker
right definitely and then you know like you said educating your patients on what does the fingertip look like do they have good capillary refill you know we want to make sure they're not putting the splints on too tight and then another key with these mallet fingers is managing the patient's expectations so if you tell them their finger is supposed to be perfectly straight then when their finger is not perfectly straight they're going to be disappointed right so i think when we started and you said they had a 10 degree
00:07:42
Speaker
a five to 10 degree lag is acceptable. I tell them that on the first visit, you know, this is what we expect. We expect we would want it to be perfect and neutral, but oftentimes you're going to end up with a five to 10 degree lag and then showing them what that looks like. So they're not disappointed or they don't think that they failed conservative treatment. Yeah. Yeah. And so let's say that they've done the six to eight weeks. They've been super compliant. They come out of it. What's the plan then? You jumping right to stretching?
00:08:10
Speaker
No, definitely not. Right, right. What about you?
00:08:15
Speaker
Uh, yeah, we're looking like three months before I'm doing any passive. And a lot of times I'll tell patients, like if they come out and they're a little stiff, I might say, you know what, go live life for a couple of weeks and come back. If at the three month mark, and maybe I'll even schedule that visit just to kind of be proactive, then they can call and cancel it. I'll say, come back at that three month mark. And if it's still stiff and it's not bending like your others, then we'll pursue passive range of motion. But live life may be enough to get it mobile again.
00:08:41
Speaker
Yeah, I think the fear is always if you're really aggressive when they come right out this plinth, you're going to detach that extensor tendon, right? Yeah, aggressive with passes. So I like you, I might show them, especially if they're really stiff, I might just show them some tendon glides, maybe joint walking, but oftentimes not. And like you said, let them go live their life and have them come back in a few weeks and see where they're at.
00:09:02
Speaker
Yeah. Yeah. And if they need some stretching, if they need, like I can even teach them at week that when they come out of it, week six or eight, whatever, just joint blocking to that DAP, give them a couple of things to do on their own. And then a lot of times I never see them again, cause they call and cancel that three and follow up cause they're doing well enough and they have maybe a little lag, but again, that's with intolerance.
00:09:21
Speaker
And then I always teach them to watch if their lag is worsening, right? So sometimes I'll have them trace their finger on a piece of paper so they can see how straight it is. And if that lag is increasing, then I'll be like, well, maybe I need to go back in your splint at night and throughout the day a little bit, just to make sure we don't lose everything that we've gained. All right. That's a ton of information on mallet fingers. That's everything from splinting to treatment to precautions and stuff. But hopefully that helps you guys out and gives you something to go with.