Orthopedics Book

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Extensor Tendon Injury at the DIP JointAka: DIP Extensor Tendon Avulsion, Mallet finger, Drop Finger, Baseball Finger

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  1. Epidemiology
    1. Most common closed finger Tendon Injury
  2. Mechanism
    1. Forced flexion of extended distal interphalangeal joint
      1. Ball strikes fingertip on catching a ball
    2. Trauma at DIP joint results:
      1. Avulsion of distal phalanx (Bony Mallet) or
      2. Extensor tendon rupture (Tendinous Mallet)
        1. Tendon stretched, or partially or completely torn
  3. Symptoms
    1. Pain and swelling at dorsal DIP joint
  4. Signs
    1. DIP joint with flexion deformity at rest
    2. Isolate the DIP joint to test active extension
      1. Variable loss of active finger DIP extension
      2. Confirm extension weakness due to extensor tendon
        1. Central slip at PIP joint can also extend DIP
  5. Radiology: XRay of digit (esp. lateral)
    1. Assess for bony mallet at dorsal base of distal phalanx
      1. Type I: No avulsion fragment
      2. Type II: Small bony avulsion
      3. Type III: Avulsion with volar subluxation
    2. Post-reduction XRay to confirm proper alignment
  6. Management: Splinting
    1. General
      1. Splints are equally effective: Aluminum, Stack, Ring
      2. Splints are as effective as surgical repair
      3. May participate in sports with splinted DIP
    2. Precautions
      1. See Orthopedic referral indications below
      2. Splint should not reduce range of motion of PIP
      3. Splinting must be continuous for entire period
      4. Risk of skin necrosis with splinting
        1. Avoid pressure to dorsum of DIP
        2. Avoid hyperextension of DIP joint
          1. Skin will blanch if DIP hyperextended
    3. Assessment
      1. Post-reduction XRay to confirm proper alignment
    4. Protocol
      1. First 6-8 weeks
        1. Splint finger in neutral extension for 6-8 weeks
        2. Splinting must be continuous without fail
          1. Twenty four hours per day
          2. Every day for 6-8 weeks
        3. Hold extension when changing splint
          1. Support distal phalanx against flat surface
          2. Ask for assistance when changing splint
          3. Allow skin to air for 10 minutes at splint change
            1. Reduces maceration at splint
        4. Restart splinting period if finger flexes
      2. Next 3-6 weeks
        1. Splint finger in extension only at night
  7. Associated conditions
    1. Volar subluxation of distal phalanx with bony mallet
  8. Orthopedic Referral Indications
    1. Joint incongruent
    2. Inability to passively extend DIP joint
      1. Suggests bone or soft tissue entrapment
    3. Fracture involves >30% of joint space
    4. Fragment displaced >2mm
    5. Open growth plate
    6. Bony avulsion >1/3 of distal phalanx
    7. Volar subluxation of distal phalanx
  9. Follow up
    1. Re-examine every two weeks until healed
    2. XRay every two weeks if bony avulsion
  10. Anticipatory Guidance
    1. Warn that patient that outcome will not be perfect
  11. References
    1. Brandenburg (1996) Consultant p.331-340
    2. Calmbach (1996) Lecture in Minneapolis
    3. Dvorak (1996) Lecture in Minneapolis
    4. Lillegard (1996) Lecture in Minneapolis
    5. Leggit (2006) Am Fam Physician 73(5):810
    6. Simpson (2001) J Hand Surg 26:32
    7. Wang (2001) Am Fam Physician 63(10):1961

Mallet finger (C0158473)

ConceptsAcquired Abnormality (T020) , Disease or Syndrome (T047)
ICD9736.1
EnglishBaseball finger, Mallet finger
Spanishdedo de beisbolista, dedo de la mano en martillo
Parent ConceptsOther acquired limb deformity (C0158463), Rupture of extensor tendon of finger (C0410049), Acquired deformity of finger joint (C0588048), Duplicate concept (C1274013)
SourcesICD9CM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Dropped finger (C0231665)

ConceptsSign or Symptom (T184)
EnglishDropped finger, Fingerdrop
Spanishdedo caido, dedo de beisbolista, dedo en martillo
Parent ConceptsFinding of finger (C0730481)
SourcesSCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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