Nonsurgical treatment of closed mallet finger fractures

Outcome Differences between Conservatively Treated Acute Bony and Tendinous Mallet Fingers

INTRODUCTION

Tendinous and bony mallets are very different injuries that present with extensor lag at the distal interphalangeal joint. This study aimed to evaluate the differences in outcomes between acute bony and tendinous mallet fingers treated conservatively with splints.

MATERIALS AND METHODS

We retrospectively collected data on patients with acute tendinous or bony mallets who received conservative treatment in our occupational therapy clinic. The patients were examined at an outpatient clinic, where data on pain, extension lag, and loss of flexion were recorded. Outcomes were classified according to the criteria described by Crawford.

RESULTS

Data were collected from 133 patients (43 with bony and 90 with tendinous mallets). We found that bony mallet patients were predominantly younger (mean, 36 vs. 46 years), and more likely to be female (60% vs. 34%), than tendinous mallet patients. We also found that tendinous mallet injuries predominantly affected the middle and ring fingers, while bony mallet injuries predominantly affected the ring and little fingers. The initial extensor lag was worse in tendinous than in bony mallets (median, 28° vs. 15°). In addition, patients with bony mallets had significantly better outcomes with regard to the extension lag (median 0° vs. 5° p = 0.003) and the Crawford Criteria Assessment (p = 0.004), compared with those with tendinous mallets.

DISCUSSION

Mallet injuries, both tendinous and bony, are common. They are often studied together and typically treated in the same manner using extension splints. However, evidence clearly shows that these are different injuries which present in the same manner. This study reinforces these findings and suggests that the outcome of conservative treatment is better for bony than for tendinous mallet fingers.

Prospective Randomized Clinical Trial Comparing 3-Point Prefabricated Orthosis and Elastic Tape Versus Cast Immobilization for the Nonsurgical Management of Mallet Finger

PURPOSE

The purpose of this randomized trial was to compare the outcomes of using a 3-point prefabricated orthosis with elastic tape versus cast immobilization for the management of nonsurgical mallet finger.

METHODS

This study was conducted in a single center. Individuals with a mallet injury requiring nonsurgical management were randomized to 6 weeks of full-time immobilization with either a 3-point prefabricated orthosis and elastic tape or a cast for distal interphalangeal joint extension. Outcomes were assessed at 12 weeks after the initiation of full-time immobilization and 6 months after injury.

RESULTS

A total of 70 individuals agreed to participate in the study between April 2017 and April 2021. No statistically or clinically significant differences were found between the groups regarding distal interphalangeal joint extension lag, distal interphalangeal joint flexion deficits, function according to the brief Michigan Hand Outcome Questionnaire, and pain on the Numeric Pain Rating Scale. The overall findings for both treatment groups included means of <15° of extensor lag and minimal pain (mean, <1.2 of 10) at the 6-month outcome assessment.

CONCLUSIONS

The use of a 3-point prefabricated orthosis with elastic tape and cast are both appropriate immobilization options for the management of nonsurgical mallet finger.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Posttraumatic Osteoarthritis of the Distal Interphalangeal Joint: A Follow-Up Study of 12 Years After Nonsurgical Treatment of Mallet Finger Fractures

PURPOSE

In treatment of mallet finger fractures (MFFs), the aim is to minimize residual extension lag, reduce subluxation, and restore congruency of the distal interphalangeal (DIP) joint. Failure to do so may increase the risk of secondary osteoarthritis (OA). However, long-term follow-up studies focusing on OA of the DIP joint after an MFF are scarce. The purpose of this study was to assess OA, functional outcomes, and patient-reported outcome measures (PROMs) after an MFF.

METHODS

A cohort study was performed with 52 patients who sustained an MFF at a mean of 12.1 years (range, 9.9-15.5 years) previously and who were treated nonsurgically. A healthy contralateral DIP joint was used as the control. Outcomes were radiographic OA, using the Kellgren and Lawrence and Osteoarthritis Research Society International classifications, range of motion, pinch strength, and PROMs (Patient-Rated Wrist Hand Evaluation, Quick Disabilities of the Arm, Shoulder, and Hand, Michigan Hand Outcome Questionnaire, 12-item Short Form Health Survey). Radiographic OA was correlated with PROMs and functional outcomes.

RESULTS

At follow-up, there was an increase in OA in 41% to 44% of the MFFs. Of all the MFFs, 23% to 25% showed a higher degree of OA than the healthy control DIP joint. Range of motion (mean difference ranging from -6° to -14°) and Michigan Hand Outcome Questionnaire score (median difference, -1.3) were decreased after MFFs but not to a clinically relevant extent. Radiographic OA was weakly to moderately correlated with functional outcomes and PROMs.

CONCLUSIONS

Radiological OA after an MFF is similar to the natural degenerative process in the DIP joint and is accompanied by a decrease in range of motion of the DIP joint, which does not clinically affect PROMs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Comparative outcomes between surgical treatment and orthosis splint for mallet finger: a systematic review and meta-analysis

Mallet finger is a commonly encountered condition in daily practice. However, there is currently no consensus on whether surgical intervention or conservative treatment with orthosis splint is superior. In this systematic review and meta-analysis, we compare the treatment outcomes between surgery and orthosis for bony and tendinous mallet finger. We searched PubMed, Embase, and the Cochrane Library according to the PRISMA guidelines from inception to January 15, 2021. The primary outcome was distal interphalangeal (DIP) joint extension lag angle, and secondary outcomes were DIP joint flexion and range of motion (ROM) angle. A total of 297 studies were initially identified, of which 13 (ten retrospective non-randomized controlled studies (non-RCTs) and three RCTs) were included in the final analysis. The results of this systematic review and meta-analysis showed that there was no high level of evidence supporting the superiority of surgery over orthosis in the treatment of mallet finger. Based on the available evidence, surgical intervention and conservative treatment with splint may offer similar clinical outcomes in both bony and tendinous mallet finger.

A Comparison of the Outcomes of Fiber-Wire® versus Stainless Steel Wire in Transosseous Wiring for Intra-Articular Fractures of the Distal Interphalangeal Joint

Background: Different surgical techniques have been described for the treatment of intra-articular fractures involving extensor tendon insertion of the distal interphalangeal joint (DIPJ), including acute and chronic bony mallet injuries. We have been using transosseous stainless-steel wire (SSW) in select patients. In 2015, we started using a non-absorbable polyester suture (2-0 Fiber-Wire®, Arthrex, Naples, FL, USA) instead of SSWs. The aim of this study is to compare the outcomes of SSW and Fiber-Wire® (FBW) in transosseous wiring for intra-articular fractures of the DIPJ.

Methods: This is a retrospective review of patients who underwent fixation of intra-articular fractures, including extensor tendon insertion of the DIPJ using a transosseous wiring technique, in the period from 2013 to 2018. SSW was used in the period from 2013 to 2014, and FBW was used from 2015 to 2018. Outcomes with regard to age, gender, time to union, range of motion at the DIPJ and complications were recorded and compared between the SSW and FBW groups.

Results: Nine patients (mean age: 38 years) underwent fixation with SSW and 10 patients (mean age: 31 years) with FBW. The operative time was significantly lower in the FBW group, and all the fractures united. There were no statistically significant differences between both groups with regard to time to union or range of motion at the DIPJ. Similar complication rates were observed in both groups.

Conclusions: The use of FBW in transosseous wiring for intra-articular fractures of the DIPJ can reduce operative time and provide functional results similar to that of SSWs. It can be considered as an alternative fixation technique for difficult intra-articular comminuted fractures of the DIPJ, including acute and chronic bony mallet injuries with joint subluxation.

Level of Evidence: Level III (Therapeutic)

Stack Splinting Versus Kirschner Wire Treatment in Acute Closed Mallet Finger Doyle I

Introduction

Mallet injuries are common and usually treated conservatively. Various systematic reviews have found a lack of evidence regarding the best management, and it is still unclear.

Objective

To evaluate the treatment efficacy of Stack Splinting compared to a Kirschner wire immobilization of acute closed mallet finger Doyle I.

Methods

From March 2019 to February 2020, 41 patients with acute close mallet finger Doyle I were treated; 19 patients were treated with Kirschner wire and 22 with Stack splinting for a mean of 6 weeks. The average patient age at the time of the injury was 43 years.

Results

Twenty-eight males and 13 females were in this study. Among them, 17 patients were injured in the little finger, 15 in the middle finger, and 9 in the ring finger. Twenty-seven of injuries suffered an aggression, 11 from falling, and 3 from sports injuries. All the fingers had typical mallet malformation. Seventeen patients treated with Kirschner wire completed the treatment with full recovery, only 7 patients treated with Stack splint completed the treatment and 15 treated with Stack splint had relapse on mallet injury.

Conclusion

Kirschner wire treatment is a simple procedure, and proves in this study that has better results in patients with acute closed mallet finger Doyle I compared to Stack splint.

Comparison of Orthosis Management Failure Rates for Mallet Injuries

Purpose

A closed mallet injury is a common finger injury involving terminal extensor tendon avulsion from its insertion on the distal phalanx. Nonsurgical treatment with continuous extension orthosis fabrication is the preferred treatment. Our purpose was to report the failure rates of orthotic management by digit and investigate other factors that contribute to failure.

Methods

This was a retrospective chart review of all patients with an isolated mallet finger injury managed at our institution from 2011 to 2019. Patient demographics, details of management, and treatment outcomes were collected. Failure rates were compared for all digits, specifically comparing the little finger versus all other digits. A categorical variable analysis was performed to identify risk factors for failure of orthosis management.

Results

Out of 1,331 identified patients, 328 met the inclusion criteria. There was no statistically significant difference of failure rate between digits. There was a trend toward the little finger failing at a higher rate (n = 131, 40%) than the other digits individually (P = .08) and combined (n = 95, 29%; P = .06). An older age at injury was associated with failure. The median patient age with failure was 54 years, versus the median patient age with nonfailure of 48 years (P < .01). The failure rate was higher in tendinous versus bony mallet injuries (n = 131, 40% vs n = 66, 20%, respectively; P < .01). The orthotic type was associated with the failure rate, and failure was highest in patients treated with Stack orthoses (n = 183, 56%; P = .01).

Conclusions

There was no significant difference in the orthotic management failure rate by digit for a mallet injury. Statistically significant risk factors for failure are increasing age, a tendinous injury, and the orthotic type. Further evaluation with a larger cohort is warranted to increase the statistical power of the findings.

Type of study/level of evidence

Therapeutic III.

Surgical treatment of the bony mallet thumb: a case series and literature review

INTRODUCTION

The aim of this study was to provide a more precise statement on the outcome after surgical treatment of a bony mallet thumb and possibly give a treatment recommendation regarding the surgical fixation method.

PATIENTS AND METHODS

All patients (n = 16) who underwent a surgical treatment for an acute bony mallet thumb fracture between January 2006 and July 2019 were enrolled. The surgical method, complications, the range of motion, tip pinch, lateral key pinch, overall grip strength, visual analog score, Disability of the Arm, Shoulder and Hand Score, Mayo Wrist Score, Patient-Rated Wrist Evaluation Score, Buck-Gramcko Score and radiologic parameters were evaluated. Further, a comprehensive literature search on PubMed was conducted covering a period from 1956 to 2021 to include all possible matching articles on the treatment of the bony mallet thumb (n = 21 articles).

RESULTS

Surgical treatment was very inhomogenous including indirect and direct K-wire fixation, screw fixation, plate fixation and anchor fixation methods. The IP joint range of motion and thumb strength ranged from 66 to 94% in comparison to the contralateral side. An open reduction led to worse functional scores compared to a closed reduction. Treatment methods in the literature were also very inhomogenous with a very low patient count, often even pooling data of bony mallet thumb fractures with bony mallet finger fractures. The risk for infection was higher in K-wire fixation methods than in open reduction and internal fixation methods.

CONCLUSION

The evidence for the best treatment of a bony mallet thumb fracture is low. On one hand the functional outcome can be inferior using an open reduction approach, but on the other hand, K-wire fixation methods with a closed reduction approach showed a higher risk for infection. Future multi-center research must be conducted to find the best treatment procedure for the best outcome of the patient.

The non-operative management of bony mallet injuries

Over a 4-year period, 218 mallet fractures in 211 adult patients were treated using a custom-made thermoplastic splint. Clinical results were collected prospectively, including the visual analogue score for pain, the range of motion and extensor lag, and the Patient Evaluation Measure (PEM). The joints were congruent in 168 and subluxed in 50. There were no differences in range of movement, extensor lag or PEM associated with articular subluxation or the size of the articular fragment. Pre-existing joint degeneration did not influence outcome. Non-surgical treatment demonstrates predictably good outcomes regardless of fragment size or subluxation in most patients and should be considered when discussing treatment for patients with bony mallet fractures.Level of evidence: III.

A Novel Hook Wire Tension Technique for the Treatment of Mallet Fractures: A Comparison with the Extension Block Pinning Technique

We developed a percutaneous surgical technique that allows early mobilization and compression for the treatment of mallet fractures. The aim of this study was to describe this novel technique called the hook wire tension technique (HWTT) and provide a clinical and radiological comparison between HWTT and the extension block pinning technique (EBT) in the treatment of mallet fractures. This retrospective study included 23 mallet fracture patients treated using HWTT and 25 patients treated using EBT. At the final follow-up visit, extension lag and flexion of the distal interphalangeal joint (DIPJ) were measured. DIPJ pain was assessed by the visual analogue scale (VAS) score, and the overall clinical outcomes were graded according to the Crawford criteria. Time to bone healing and osteoarthritis development were assessed radiologically. Complications, including skin necrosis, dorsal prominence and nail deformity, were also compared. The mean follow-up period was 18 months (range: 12-24) in the HWTT group and 19.2 months (range: 12-26) in the EBT group (p = 0.239). There was no statistically significant difference between the two groups in terms of mean extension lag of the DIPJ, mean VAS scores and mean time to bone healing (p > 0.405). The mean DIPJ flexion was greater in the HWTT group compared with the EBT group (p = 0.001). According to the Crawford criteria, outcomes were similar in both groups (p = 0.370). No statistically significant difference was found between the two groups when each complication was compared (p > 0.358). The short-term clinical and functional results of HWTT were found to be similar to those of EBT in the surgical treatment of mallet fractures.

Outcomes of conservative treatment for bony mallet fingers

BACKGROUND

The treatment strategy for bony mallet fingers remains controversial. The outcomes of conservative treatment were investigated in this study. In addition, the time to bone union, and gap between the bone fragment and distal phalanx are discussed.

METHODS

The subjects were 26 patients (27 fingers) with bony mallet fingers (20 males and 6 females, mean age: 46.0 years old, the mean limitation of extension of the distal interphalangeal (DIP) joint: - 20.2°). In conservative treatment, splinting was applied for 6 weeks, followed by 2-week taping. The time to bone union, range of motion of the DIP joint, and the Crawford classification on the final follow-up were investigated. In addition, the bone fragment occupation rate was evaluated on plain radiography on the first examination. Furthermore, the gap on the first examination and after splinting. The relationship between the gap and bone union period was also investigated.

RESULTS

The mean time from injury to bone union was 170.2 days, the mean range of motion of the DIP joint was - 8.5° in extension and 60.9° in flexion, and the Crawford classification was Excellent for 22 fingers, Good for 2, Fair for 2, and Poor for 1. On the first examination, the mean bone fragment occupation rate was 44.0%. The mean gap on the first examination was 1.1 mm and this was significantly narrowed to 0.8 mm after splinting (p < 0.01). No significant correlation was noted between the time to bone union and gap on the first examination (p = 0.16), however, a significant positive correlation was noted between them after splinting (p < 0.01).

CONCLUSIONS

This study suggested that a favorable clinical outcome can be achieved by conservative treatment. Moreover, the bone union period decreased as the gap after splinting decreased, being significantly correlated.

Splinting versus extension-block pinning of bony mallet finger: a randomized clinical trial

Surgical treatment of bony mallet fingers is frequently recommended, but the evidence is sparse. This randomized clinical trial aimed to compare nonoperative splinting versus extension-block pinning of bony mallet fingers with involvement of more than one-third of the joint surface but without primary joint subluxation. Thirty-two patients were randomized and 28 fulfilled the protocol. At 6 months follow-up, there were no significant differences in active extension lag in the distal interphalangeal joint (the primary outcome) or in patient-reported function and pain scores. Flexion and active range of motion in the distal interphalangeal joint and finger-to-palm distance were better in the splinting group, but three patients developed secondary subluxation. We conclude from this study, that splinting these injuries is safe and efficient in restoring joint motion, but splinting does not sufficiently prevent secondary subluxation of the joint. Radiographic follow-up during splinting appears to be necessary. Level of evidence: I.

A Trial of the Effect of 2-Step Orthosis Treatment for Mallet Finger Fractures

CONTEXT

Many patients report poor therapeutic outcomes following mallet finger fracture surgery. A more reliable technique is urgently needed.

OBJECTIVE

To present a novel treatment for mallet finger fractures using a 2-step orthosis method.

DESIGN

Prospective, observational study.

SETTING

Hospital.

PARTICIPANTS

Patients with mallet finger fractures.

INTERVENTIONS

The finger is fixed with splints for 6 weeks, including 3 weeks for the proximal interphalangeal joint in the flexion position and the distal interphalangeal joint in the hyperextension position (first splint) and 3 weeks for the distal interphalangeal joint in the hyperextension position (second splint). Up to week 8, the second splint was attached at night and during physical exertion.

MAIN OUTCOME MEASURES

Crawford criteria, Abouna-Brown criteria, bone fusion, grip strength, Doyle classification, Ishiguro classification.

RESULTS

Sufficient bone fusion was achieved 12 weeks after fixation; at which time, the range of motion with the distal interphalangeal joint flexed, and extended in the 3 patients was 50° and 0°, 70° and -3°, and 60° and 0°, respectively. The right and left hand grip strengths in the 3 patients were 58 and 55 kg, 62 and 58 kg, and 31 and 29 kg, respectively; there were no problems with respect to function or work. The first 2 patients could start sports again with partial return after 1 week and complete return after 12 weeks and 8 weeks, respectively. For the third patient, rehabilitation was complete after 16 weeks. Evaluation of the fracture sites based on the Crawford criteria showed the condition to be perfect, and evaluation based on the Abouna-Brown criteria showed success.

CONCLUSIONS

This method provides satisfactory fixation and can prevent proximal interphalangeal joint contracture. Favorable long-term outcomes were confirmed in all patients, suggesting that this method may be effective for previously untreated mallet finger fractures with little displacement.

A Comparison of Splint Versus Pinning the Distal Interphalangeal Joint for Acute Closed Tendinous Mallet Injuries

Background: The vast majority of acute closed tendinous mallet injuries are treated with a splint. Very few studies have directly compared splinting versus pinning the distal interphalangeal joint for this injury. The aim of this cohort study is to determine the outcomes of both methods. Methods: A total of 59 patients with acute tendinous mallet injury were retrospectively enrolled (29 patients in conservative treatment and 30 patients in surgical treatment). Conservative treatment was performed using custom-made thermoplastic splint and surgical treatment was conducted with oblique K-wire fixation of the distal interphalangeal (DIP) joint. The DIP joint was immobilized for eight weeks in both treatments. Active ranges of motion of the affected finger and Miller's classification were evaluated postoperatively. Results: The mean extension lag of the DIP joint in the surgical treatment group was significantly better than it was with conservative treatment (2.1° vs 13.8°). Three patients who were noncompliant with the splint showed poor results, while no patients in the surgical treatment group had a poor result. Conclusions: Surgical treatment with K-wire fixation leads to satisfactory results for acute tendinous mallet injury.

Extensor Tendon Injuries in the Athlete

An athlete's hands are susceptible to a variety of acute and cumulative traumas depending on their chosen sport. Depending on the timing of the injury, the immediate requirements of the athlete, and future aspirations, treatment strategies may need individual customization. This article offers a brief review of the anatomy and complex function of the extensor mechanism, discusses the etiologies of various extensor injuries, and outlines the multiple treatment options and expected outcomes.

Outcome of Hook Plate Fixation of Mallet Fractures

BACKGROUND

Hook plate fixation of closed mallet fractures was first described in 2007, but there has subsequently been a lack of studies examining the outcomes and complications of this technique.

METHODS

This paper aims to assess the clinical outcomes of hook plate fixation of closed mallet fractures by retrospectively reviewing 31 closed, bony mallet injuries that were surgically fixed with a hook plate between 2002-2011.

RESULTS

Patients who underwent hook plate fixation had a median time to radiographic union of 83 days. Pre-operative median distal interphalangeal joint (DIPJ) extensor lag was 20°, with a post-operative extensor lag of 0°. Median DIPJ flexion was 60°, with 58% of all cases achieving greater than 50° of DIPJ flexion. There were 4 instances of minor complications (i.e. transient nail deformity and marginal skin flap ischaemia), with 3 cases of major complications (i.e. fracture redisplacement).

CONCLUSIONS

Our results show that the hook plate technique has satisfactory functional outcomes and an acceptable complications rate compared to other treatment modalities in the existing literature. Nevertheless, the outcomes of this technique in our sample population were not as excellent as initially reported.

LEVEL OF EVIDENCE

Level IV: Retrospective case series, Therapeutic Studies.

Management of Acute Extensor Tendon Injuries

Thin soft tissue covering extensor tendons make them prone to injury. The extensor mechanism achieves a delicate balance with the flexor system. Inappropriate management in the acute setting can lead to long-term deformity and dysfunction. Acute extensor tendon injuries are usually managed with splinting and/or primary repair of the tendon. In cases of tendon length loss, tendon graft or flap may be necessary for reconstruction. This article presents a series of cases illustrating the appropriate management of traumatic extensor tendon injuries.

When the Injury's Healing Process Meets the Needs of a Top-Level Volleyball Player: A Nonconventional Treatment of a Mallet Fracture Reinjury

Managing top-level athlete's recovery after an injury is very complicated because it requires a challenging combination of clinical and social/professional aspects with the need to return as soon as possible to sports play. Herein, we report a top-level volleyball player for whom a finger splint combined with a custom made thermoplastic protection was used for the conservative management of a Mallet fracture reinjury. This way our player continued training and competitions in contrast to conventional rehabilitation protocols, which suggest to avoid new traumas until the healing phase is completed. After 8 wks, we obtained the fracture healing and a complete functional recovery without major medical complications. From our results, we suggest that novel treatment strategies or modification of conventional rehabilitation protocols are worth consideration for the management of high-level sports players' injuries. However, new clinical studies with a larger sample can compare these results with those resulting from both surgical procedures and from immobilization and rest as well.

Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review

PURPOSE

The current literature describes multiple surgical and nonsurgical techniques for the management of mallet finger injuries, and there is no consensus on the indications for surgical treatment. The objective of this study was to determine, through a literature review, if any conclusions can be drawn concerning the indications for surgery in mallet finger injuries; the treatment outcomes of surgical versus nonsurgical management; the most effective methods of surgical and nonsurgical treatment; and the most common treatment complications of mallet finger injuries.

METHODS

A systematic review of multiple databases was performed. English language clinical studies evaluating therapeutic interventions for mallet fingers that reported objective, standardized outcome measures were included. Basic science studies, cadaveric studies, conference abstracts, level V evidence studies, studies lacking statistical data, and tendinous injuries other than mallet fingers were excluded. Salvage procedures and studies evaluating exclusively chronic lesions were also excluded.

RESULTS

Forty-four studies that reported clinical outcomes for the treatment of mallet finger injuries, 22 evaluating surgical treatments and 17 studies investigating nonsurgical treatments were included. The average distal interphalangeal joint extensor lag was 5.7° after surgical treatment and 7.6° after nonsurgical treatment. Complication rates of surgical and nonsurgical interventions were comparable (14.5% and 12.8%, respectively). Five studies directly compared the outcomes of surgical with nonsurgical management, with mixed results and recommendations.

CONCLUSIONS

Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes. Insufficient evidence is available to determine when surgical intervention is indicated. Based on our literature review, it appears that these treatments are equivalent and should be individualized to the patient.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Effects of health literacy on treatment outcome and satisfaction in patients with mallet finger injury

STUDY DESIGN

Prospective cohort.

INTRODUCTION

Patient comprehension of their injury, its treatment, and health care provider's instructions plays an important role in health management and recovery from trauma.

PURPOSE OF THE STUDY

This study investigates the effects of health literacy (the ability to obtain, process, and understand health information needed to make appropriate health decisions) on treatment outcomes and satisfaction in patients with mallet finger injuries.

METHODS

A total of 72 patients who had been treated with an orthosis for an acute mallet finger injury were enrolled in this prospective study. Health literacy was measured according to the newest vital sign during the initial visit, and adherence according to the treatment protocol was rated at week 7 when orthotic intervention was ceased. At 6 months, a follow-up visit was conducted to assess the extensor lag, treatment satisfaction, and disability (through the Quick Disabilities of the Arm, Shoulder, and Hand score). Bivariate and multivariable analyses were performed to determine whether patient demographics, injury characteristics, and health literacy factors accounted for following outcomes: extensor lag, satisfaction, and disability.

RESULTS

The newest vital sign scores were moderately correlated with patient adherence and age. Extensor lag was associated with an increase in age, poor adherence, and low health literacy, and these 3 factors accounted for 28% of the variation in the extensor lag. A greater disability was associated with poor adherence, which accounted for 12% of the variance in disability. Lower treatment satisfaction was associated with low health literacy and poor adherence, and these 2 factors accounted for 21% of the variation in treatment satisfaction.

DISCUSSION AND CONCLUSIONS

Limited health literacy was associated with poor adherence in orthosis care for mallet finger injuries and led to poorer treatment outcomes in terms of extensor lag and treatment satisfaction.

LEVEL OF EVIDENCE

2B.

ICF components of outcome measures for mallet finger: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION/PURPOSE

The purpose of this study was to systematically review outcome measures used for the assessment of the conservative management of mallet finger to determine if they characterize the International Classification of Functioning, Disability, and Health components of activity, participation, environmental factors, or quality of life.

METHODS/RESULTS

Five studies published within the last 10 years were included in the systematic review. A majority, 19 of the outcomes used by the authors, fell within the body functions and structures category. Six were related to activity, and 1 was related to participation. One was linked to environmental factors. Five were found to be not definable and related to quality of life.

DISCUSSION/CONCLUSION

This systematic review suggests that many outcome measures focus on body structures and functions in the current research on the conservative treatment of mallet finger injuries.

LEVEL OF EVIDENCE

2a.

The Outcomes of Extension Block Pinning and Nonsurgical Management for Mallet Fracture

PURPOSE

We aimed to compare the clinical and radiographic results of patients with a mallet fracture involving more than one-third of the articular surface, but without a high degree of distal interphalangeal (DIP) joint subluxation, treated with extension block pinning or nonsurgical management.

METHODS

Forty-nine patients with a mallet fracture involving more than one-third of the articular surface were reviewed. Twenty-six cases were treated using extension block pinning (surgery group) and 23 were treated nonsurgically (nonsurgical group). At the final follow-up, extension lag and flexion of the DIP joint of the affected digit were measured. Distal interphalangeal joint pain was rated using a visual analog scale and the overall clinical outcomes were graded using Crawford's criteria. Complications, including nail deformity and dorsal prominence, were also assessed. The rate of DIP joint subluxation and fracture fragment size were radiographically evaluated.

RESULTS

Mean extension lag and flexion of the DIP joint and mean visual analog pain scores were not significantly different in the 2 groups. Outcomes, as assessed using Crawford's criteria, were excellent in 5, good in 12, fair in 6, and poor in 3 in the surgery group, and excellent in 2, good in 11, fair in 8, and poor in 2 in the nonsurgical group. Moreover, the frequency of nail deformity or dorsal prominence was similar in the 2 groups. The rate of DIP subluxation and mean fracture fragment size were similar between the 2 groups. All the fractures had united by 3 months after injury in both groups.

CONCLUSIONS

The clinical outcomes do not significantly differ between extension block pinning and nonsurgical management for mallet fractures involving more than one-third of the articular surface, but without high degree subluxation of the DIP joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Diagnosis and Management of Mallet Finger Injuries

BACKGROUND

Mallet finger is a common injury of the extensor tendon insertion causing an extension lag of the distal interphalangeal joint.

METHODS

We reviewed the most current literature on the epidemiology, diagnosis, and management of mallet finger injuries focusing on the indications and outcomes of surgical intervention.

RESULTS

Nonoperative management has been advocated for almost all mallet finger injuries; however, complex injuries are usually treated surgically. There is still controversy regarding the absolute indications for surgical intervention.

CONCLUSIONS

Although surgery is generally indicated in the case of mallet fractures involving more than one-third of the articular surface as well as in all patients who develop volar subluxation of the distal phalanx, a significant advantage of surgical management even in those complicated cases has yet to be clearly proven.

A review of mallet finger and jersey finger injuries in the athlete

PURPOSE OF REVIEW

The purposes of this review are to discuss the diagnosis and management of mallet and jersey finger injuries in athletes and to highlight how treatment impacts return to play.

RECENT FINDINGS

Mallet finger: although numerous non-operative and operative techniques have been described, there continues to be little consensus regarding the optimal procedure. Jersey finger: ultrasound appears to be a cost-effective imaging modality that may be useful for preoperative planning. Wide-awake surgery offers optimal intraoperative assessment of the tendon repair. Tendon repair with volar plate augmentation has been shown to improve the strength of the repair in the laboratory, and early clinical results are encouraging. Most mallet finger injuries will heal with non-operative treatment over a period of 8-12 weeks, even when treatment is delayed up to 3-4 months. An acute diagnosis of jersey finger requires surgical treatment and generally means 8-12 weeks of inability to compete in most contact sports.

Phalanx fractures and dislocations in athletes

PURPOSE OF REVIEW

Phalangeal fractures, dislocations, and fracture-dislocations in the hand are common injuries. We review the current literature on the diagnosis and treatment of these injuries in the athlete. An understanding of the anatomy and its relationship to the mechanism of injury may help to direct appropriate management. Return to play remains an important concern to the patient-athlete.

RECENT FINDINGS

Findings from recently published articles reinforce previously established treatment methods in the management of finger phalangeal fractures, dislocations, and fracture-dislocations. The majority of these injuries can be treated non-operatively. Technological advances in implant designs may conceivably allow for earlier rehabilitation and, in turn, a more expeditious return to sport. Management of phalangeal injuries in the elite athlete often necessitates special treatment considerations. The majority of phalangeal bone and joint injuries in the athlete can be treated in a comparable manner to the non-athlete. The goals of treatment are restoration of bone and joint alignment and stability in order to hasten a return to competition. Surgery as a means to expedite return to play in the high-level athlete should be determined on a case by case basis. Technological improvements in surgical implants may enable accelerated postoperative recovery. However, to our knowledge, there are no published studies to definitively support this assumption.

Finger Injuries in Ball Sports

Finger injuries are common in athletes playing in professional ball sports. Understanding the intricate anatomy of the digit is necessary to properly diagnose and manage finger injuries. Unrecognized or poorly managed finger injuries can lead to chronic deformities that can affect an athlete's performance. Multiple factors and treatment options should be considered to provide the best functional outcome and rapid return to play for an athlete. This article discusses the mechanism of injury, diagnosis, treatment, and return-to-play recommendations for common finger injuries in ball sports.

Pediatric Phalanx Fractures

Phalangeal fractures are the most common type of hand fracture that occurs in the pediatric population and account for the second highest number of emergency department visits for fractures in the United States. The incidence of phalangeal fractures is the highest in children aged 10 to 14 years, which coincides with the time that most children begin playing contact sports. Younger children are more likely to sustain a phalangeal fracture in the home setting as a result of crush and laceration injuries. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. A thorough physical examination is necessary to assess the digital cascade for signs of rotational deformity and/or coronal malalignment. Plain radiographs of the hand and digits are sufficient to confirm a diagnosis of a phalangeal fracture. The management of phalangeal fractures is based on the initial severity of the injury and depends on the success of closed reduction techniques. Nondisplaced phalanx fractures are managed with splint immobilization. Stable, reduced phalanx fractures are immobilized but require close monitoring to ensure maintenance of fracture reduction. Unstable, displaced phalanx fractures require surgical management, preferably via closed reduction and percutaneous pinning.

How do hand therapists conservatively manage acute, closed mallet finger? A survey of members of the British Association of Hand Therapists

Introduction

Previous research concerning the conservative management of mallet finger has focused on splint application, with limited representation of supplementary rehabilitation and best practice. This research sought to investigate the practice and opinions of members of the British Association of Hand Therapists regarding their current treatment and to determine whether any specific exercise prescription or rehabilitation protocols are followed.

Methods

British Association of Hand Therapists members were contacted via e-mail and requested to complete an online survey. Thirty-five responses (5.7% response rate), 30 (4.8% response rate) of which were fully completed were obtained over the eight-week data collection period. The questionnaire consisted of 30 questions (20 quantitative and 10 qualitative) concerning therapists’ roles and condition management. Responses were analysed in terms of response frequencies, percentages and thematic text analysis.

Results

The results demonstrated current clinical practices in line with available best-evidenced practice. Conservative therapeutic management is diverse and varied. Therapists believe their role to be significant in optimising outcome success.

Discussion

Exercises and other interventions supplementary to splinting are commonly utilised in the therapeutic management of acute, closed mallet finger. This research found hand therapists implement a diverse range of clinical skills in order to optimise outcome success. Recommendations for best practice and further research are presented.

Conservative treatment of mallet finger: A systematic review

PURPOSE

To determine if there is a superior orthosis and wearing regimen for the conservative treatment of mallet finger injuries. The secondary purpose is to examine the current evidence to evaluate if a night orthosis is necessary following the initial immobilization phase.

METHODS

A comprehensive literature search was conducted using the search terms mallet finger, splint, orthosis, and conservative treatment.

RESULTS

Four randomized controlled trials (RCTs) were included in the systematic review. In all 4 RCTs mallet fingers were immobilized continuously for 6 weeks in acute injuries and 8 weeks for chronic injuries.

CONCLUSIONS

Two of the three studies found a large effect size for orthotic intervention ranging from 2.17 to 12.12. Increased edema and age and decreased patient adherence seem to negatively influence DIP extension gains. Recommended immobilization duration is between 6 to 8 weeks and with additional weeks of immobilization in cases of persistent lags.

LEVEL OF EVIDENCE

1a.

A systematic review of questionnaires to assess patient satisfaction with limb orthoses

BACKGROUND

Assessment of patient satisfaction with orthosis is a key point for clinical practice and research, requiring questionnaires with robust psychometric properties.

OBJECTIVES

To identify which validated questionnaires are used to investigate patient satisfaction with orthosis in limb orthotics and to analyse (1) their main fields of clinical application, (2) the orthosis-related features analysed by the questionnaires and (3) the strength of their psychometric properties.

STUDY DESIGN

Systematic review.

METHODS

A literature search using MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus databases for original articles published within the last 20 years was performed.

RESULTS

A total of 106 papers pertaining to various clinical fields were selected. The main features of patient satisfaction with orthosis analysed were as follows: aesthetic, ease in donning and doffing the device, time of orthotic use and comfort.

CONCLUSION

Of the questionnaires used to investigate patient satisfaction with orthosis, only four are adequately validated for this purpose: two for generic orthotic use (Quebec User Evaluation of Satisfaction with assistive Technology 2.0 and Client Satisfaction with Device of Orthotics and Prosthetic Users' Survey) and two for specific application with orthopaedic shoes (Questionnaire for the Usability Evaluation of orthopaedic shoes and Monitor Orthopaedic Shoes). Further development, refinement and validation of outcome measures in this field are warranted.

CLINICAL RELEVANCE

Given the importance of analysing patient satisfaction with orthosis (PSwO), appropriate instruments to assess outcome are needed. This article reviews the currently available instruments and reflects on how future studies could be focused on the development, refinement and validation of outcome measures in this field.

Pressing fixation of mallet finger fractures with the end of a K-wire (a new fixation technique for mallet fractures)

AIM

The aim of this study was to describe and evaluate a surgical technique for the treatment of mallet finger fractures using a K-wire stabilization of the distal interphalangeal (DIP) joint and another K-wire pressing the bone fragment.

METHODS

Between June 2007 and March 2014, 41 patients (28 men, 13 women) with isolated closed mallet finger fracture were treated using two K-wires. In the cohort, the mean joint surface involvement was 44.3% (range: 28-62%). With a mean period of 23.6 months, patient follow-up lasted 13-34 months. The fingers were evaluated for loss of extension and flexion of the (DIP) joints. The results were graded using Crawford's criteria.

RESULTS

Union of all fractures took place at an average of 5.5 weeks after the surgical procedure. Average extension lag was 4°, and active flexion 71°. According to the Crawford rating scale, 35 fingers were excellent, four were good, one was fair, and one was poor.

CONCLUSIONS

Pressing fixation of the bone fragment with the end of a K-wire was a useful technique in the treatment of mallet finger fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinical comparison of hook plate fixation versus extension block pinning for bony mallet finger: a retrospective comparison study

The aim of this retrospective study was to determine whether traumatic mallet fractures had better outcomes when treated by hook plate fixation (13 patients) or extension block pinning (19 patients). We assessed outcomes using Crawford's criteria; distal interphalangeal joint range of motion; the DASH score; and a visual analogue scale score for pain. We measured radiological parameters. No significant differences were observed in functional and clinical outcomes and in complications. Whereas the operative time was longer in the hook plate group, intraoperative fluoroscopy use, time to bone union and time to return to work were greater in the extension block group. Although the hook plate method is more technically demanding, it provides good stable reduction, earlier mobilization and an earlier return to work. The extension block pinning technique is easier and as effective but it requires greater peri-operative fluoroscopy. Level of evidence: Level III.

Pullout wire fixation together with distal interphalangeal joint Kirschner wire stabilization for acute combined tendon and bone (double level) mallet finger injury

This article describes a previously unclassified type of combined tendon/bone mallet finger. This supplements the conventional Doyle classification. The article also describes the technique for surgical treatment of such mallet fingers, which involves the use of a pullout wire with K-wire stabilization of the distal interphalangeal joint.

The risk factors associated with subluxation of the distal interphalangeal joint in mallet fracture

Surgical fixation is recommended when a mallet fracture involves more than one-third of the articular surface of the distal phalanx. This recommendation originates from the idea that involvement of more than one-third of the base of the distal phalanx causes subluxation of the distal interphalangeal (DIP) joint. Eighty-six fingers of 85 patients with a mallet fracture involving more than one-third of the articular surface of the distal phalanx were enrolled in this study. Patients were allocated on the basis of subluxation of the DIP joint into a group with no subluxation or a group with subluxation. These two groups were compared with respect to age, sex, fracture size, fracture displacement, time to finger immobilizer application, and initial extensor lag of the DIP joint. Backward stepwise multiple logistic regression analysis was performed to identify the risk factors of DIP joint subluxation, and receiver operating curve analysis was used to calculate the optimal cut-off point for the risk factors. Half of our patients with a mallet fracture involving > one-third of the articular surface of the distal phalanx showed subluxation of the DIP joint. A significant intergroup difference was found for fracture size and time to application of a finger immobilizer, but no significant difference was observed for other parameters. The risk factors of DIP joint subluxation were fracture size and time to application of finger immobilizer. The optimal cut-off values for the development of DIP joint subluxation were 48% for the fracture size and 12.5 days for time to finger immobilizer application.

Mallet fingers with bone avulsion and DIP joint subluxation

One-third of all mallet fingers are associated with a fracture. Mallet fractures associated with large fracture fragments may result in volar subluxation of the distal phalanx. The management of mallet fractures varies based on injury pattern and surgeon preference. These treatment options include splinting regimens, closed reduction and percutaneous pinning and open reduction and internal fixation. Although numerous surgical techniques have been described, there is little clear consensus on operative treatment. Moreover, there is insufficient evidence to support operative over nonoperative treatment for mallet fractures.

Transtendinous wiring of mallet finger fractures presenting late

PURPOSE

To determine if transtendinous wiring was an effective late treatment for bony mallet injuries.

METHODS

Between 2005 and 2011, 19 consecutive patients (13 men, 6 women) with a mean age of 29 years (range, 13-52 y) were treated late for mallet finger fractures. The mean interval from injury to initial operation was 57 days (range, 28-141 d).

RESULTS

Fifteen of 18 mallet fractures demonstrated evidence of radiographic healing after an average of 6 weeks (range, 5-10 wk). One patient developed ankylosis, and 3 patients failed to achieve bone union at the final follow-up. The mean motion of the distal interphalangeal joint was 73° (range, 35°-95°), and the mean extension lag was 7° (range, 0°-25°).

CONCLUSIONS

Transtendinous wiring was an effective late treatment for mallet fractures, demonstrating satisfactory fixation, allowing early mobilization, and showing good functional results while avoiding salvage operations.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Extensor tendons injuries

Extensor mechanism injuries are frequently encountered in athletes and can lead to permanent disability or deformity if not promptly and properly treated. This article reviews basic anatomy, and then discusses mallet finger injuries, boutonniere deformity, and sagittal band rupture. Once treatment has begun, return to sport is highly variable because of the varied needs of each athlete and where they fall on the spectrum of disease. As such, each athlete must be carefully evaluated and closely followed to ensure a safe, prompt, and judicious return to athletic pursuits.

A prospective randomized controlled trial comparing night splinting with no splinting after treatment of mallet finger

BACKGROUND

The effectiveness of night splinting after treatment of mallet finger is unknown. We tested the hypothesis that there is no difference in extensor lag between patients with mallet finger that wear a night splint for an additional month after 6 to 8 weeks of continuous splinting and patients that do not wear a night splint.

METHODS

Fifty-one patients were enrolled in this randomized controlled trial. At enrollment, range of motion was measured for the injured and contralateral uninjured finger. The follow-up was conducted approximately 4 weeks later in person (41 patients) or by phone (10 patients). Analysis was by intention to treat.

RESULTS

There were no significant differences in final extensor lag between patients that did and did not receive a night splint. Among the 41 patients with a final in-person evaluation, the final average extensor lag was 14°, and 34 % (14 of 41 patients) had a lag of 20° or greater. Final extensor lag correlated significantly with age, enrollment distal interphalangeal joint (DIP) flexion and extensor lag, and final DIP flexion, with the latter two accounting for 28 % of the variation in final lag in the final multivariable model (p < 0.001). There were no differences in disability (p = 0.67) or treatment satisfaction (p = 0.48) between patients that did and did not use night splints.

CONCLUSIONS

Supplemental night splinting does not improve the outcome of mallet finger in terms of extensor lag, disability, or satisfaction with treatment. Patients with worse initial extensor lags should expect worse final lags; residual lags of 20° or greater are commonplace.

[Injuries of the distal interphalangeal joints]

Injuries of the distal interphalangeal joints mostly involve the extensor tendon. Its superficial position on the dorsal aspect of the finger often exposes the extensor tendon to closed and open injuries. Lesions of the extensor tendons are more common than those of the flexor tendons. Furthermore, injuries of the joint often occur as fractures of the dorsal base of the distal phalanx, and, less frequently, as fractures of the head of the middle phalanx. In all cases, correct diagnosis and therapy is essential. Incorrect diagnosis and neglecting of the injury by both surgeon and patient often lead to considerable complications, e.g., delayed healing and lack of function.

Fracture dislocation of the finger joints

Fracture dislocations of the hand are difficult and often unforgiving injuries. Keys to treatment include early recognition, stable concentric reduction, and protected early active range of motion maintaining joint stability. The balance between stability and mobility is difficult to manage; therefore, surgeons need a wide array of treatments to tailor management to the specific fracture pattern. With appropriate treatment, residual stiffness and pain can be minimized. This Current Concepts review aims to provide up-to-date management for proximal interphalangeal, distal interphalangeal, and metacarpophalangeal joint fracture dislocations.

Effectiveness of cast immobilization in comparison to the gold-standard self-removal orthotic intervention for closed mallet fingers: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

INTRODUCTION

Although orthotic immobilization has become the preferable treatment choice for closed mallet injuries, it is unclear whether orthosis self-removal has an impact on the final outcome.

PURPOSE

To evaluate the treatment efficacy of cast immobilization of closed mallet fingers using Quickcast(®) (QC) compared to a removable, lever-type thermoplastic orthosis (LTTP).

METHODS

57 subjects were randomized in 2 groups. DIPj extensor lag and the Gaberman success scale were used as primary outcomes.

RESULTS

LTTP subjects resulted in greater extensor lag than QC subjects (x = 5°; p = 0.05) at 12 weeks from baseline, and high edema and older age negatively affected DIPj extensor lag. No other differences were found between groups.

CONCLUSION

Cast immobilization seems to be slightly more effective than the traditional approach probably for its greater capacity to reduce edema.

LEVEL OF EVIDENCE

1B.

Tendon-bone graft for tendinous mallet fingers following failed splinting

PURPOSE

To describe and assess a surgical technique for the treatment of tendinous mallet fingers after failed conservative treatment.

METHODS

From January 2010 to March 2012, 28 tendinous mallet fingers in 28 patients were treated. All patients had greater than 25° extensor lags after 6 to 8 weeks of splinting. Four patients had a second trial of splinting, which also failed. A tendon-bone graft, taken from the extensor carpi radialis brevis and the third metacarpal base, was used for reconstruction. The mean time between the injury and operation was 74 days. The mean preoperative extension lag was 34°. Five patients reported pain in the distal interphalangeal joint. At the final follow-up, patients rated the level of pain on the distal interphalangeal and wrist joints using a visual analog scale. Joint motion was graded with the Crawford criteria. Hand function was assessed with the Disabilities of the Arm, Shoulder, and Hand questionnaire. Patients reported on their satisfaction based on the Michigan Hand Outcomes Questionnaire.

RESULTS

Bone healing was achieved in all patients at a mean of 5 weeks. Position of bone graft was maintained until bone healing was evident in all cases. At the mean follow-up period of 15 months, nail deformity was not noted. No patient reported pain on the distal interphalangeal joint or wrist. The mean residual extension lag of the distal interphalangeal joints was 4°. The results showed that 24 digits were excellent and 4 were good based on the Crawford criteria. The Disabilities of the Arm, Shoulder, and Hand scores averaged 1, and 27 patients were satisfied with appearance of the hand. One patient sometimes felt uncomfortable regarding the appearance.

CONCLUSIONS

A tendon-bone graft is a useful and reliable technique for the treatment of tendinous mallet fingers after failed splinting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Pediatric hand fractures

Pediatric hand fractures are common childhood injuries. Identification of the fractures in the emergency room setting can be challenging owing to the physes and incomplete ossification of the carpus that are not revealed in the radiographs. Most simple fractures can be treated with appropriate immobilization through buddy taping, finger splints, or casting. If correctly diagnosed, reduced, and immobilized, these fractures usually result in excellent clinical outcomes.

Intra-articular fractures of the hand

Fractures of the hand are common injuries and in particular, fractures involving the articular surfaces can present difficulties to the orthopedic surgeon in practice. Although the treatment of these fractures needs to be individualized based on fracture pattern and location, the goals for these fractures are to restore the alignment, stability, and congruity and to allow for early motion to prevent stiffness and traumatic arthritis. This article classifies the various types of intra-articular hand fractures as well as the workup and management of these injuries.

Peak load resistance of the JuggerKnot™ soft anchor technique compared with other common fixation techniques for large mallet finger fractures

INTRODUCTION

To identify the strongest peak load resistance among four mallet finger fracture fixation methods (Kirschner wire, pull-out wire, tension-band wiring and the JuggerKnot™ (Biomet) soft anchor fixation).

METHODS

Fixation techniques were assigned among 24 specimens from six cadaveric human hands in a randomized block fashion. Peak load resistance was tested at 30°, 45° and 60° of flexion of the distal interphalangeal joint.

RESULTS

The mean peak load of tension-band wiring was 67.8 N at 60° of flexion which was most superior. The JuggerKnot™ fixation had mean peak loads of 13.35 N (30°), 22.51 N (45°) and 32.96 N (60°). No complications of implant failure or fragmentation of the dorsal fragment was noted.

CONCLUSIONS

Tension-band wiring was the strongest fixation method but was most prominent on the skin surface as seen in three specimens. The JuggerKnot™ soft anchor fixation had similar peak load resistance as k-wire fixation and pull-out wiring.

Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement to assess reporting of observational trials in hand surgery

PURPOSE

To use the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist to critically evaluate the change in quality of observational trial reporting in the Journal of Hand Surgery American between 2005 and 2011.

METHODS

A cross-sectional analysis of observational studies published in the Journal of Hand Surgery American was designed to sample 2 6-month periods of publication (March 2005 to August 2005 and June 2011 to November 2011). Fifty-one items were extracted from the STROBE statement for evaluation. Overall STROBE compliance rates for articles and specific checklist items were determined. Final compliance percentages from each period were compared by Student t-testing. Changes in item compliance over time were quantified.

RESULTS

Overall compliance with the STROBE statement was 38% (range, 10%-54%) in 2005 and 58% (range, 39%-85%) for 2011 manuscripts representing a significant improvement. Seventy-five percent or greater of articles (2005/2011) provided the explicit reporting of background (100%/97%), follow-up time (85%/94%), overall interpretation of data (100%/94%), and results of similar studies (95%/89%). Twenty-five percent or less of articles provided the study design in the abstract (10%/20%), a clear description of the study's setting (10%/23%), the handling of missing data (0%/6%), the potential directions of bias (5%/11%), and the use of a power analysis (0%/17%). Eighty-six percent (44/51) of items were more frequently satisfied in 2011 articles than in 2005 publications. Absolute increases in compliance rates of 40% or greater were noted in 10 items (20%) with no worsening in compliance for an individual item over 6%.

CONCLUSIONS

The overall quality of the reporting of observational trials in the Journal of Hand Surgery American improved from 2005 to 2011. Current observational trials in hand surgery could still benefit from increased reporting of methodological details including the use of power analyses, the handling of missing data, and consideration of potential bias.

LEVEL OF EVIDENCE

Diagnostic III.

A MODIFIED TENSION BAND WIRING TECHNIQUE FOR TREATMENT OF THE BONY MALLET FINGER

Purpose: To report the outcomes of mallet fractures treated with our modified tension band wiring technique.

Methods: Eleven men and two women (mean age; 33 years) with mallet fractures in which happened more than five weeks before surgery, or with fracture fragments involving more than 2/3 or less than 1/3 of the distal phalanx articular surface or with previous surgical intervention, were subjected to this study. The fracture fragment was fixed with a modified tension band wiring technique using a stainless steel wire and an injection needle.

Results: All patients achieved bone union in nine weeks in average. All patients had no pain except one with mild pain. No patient showed a gap or step-off greater than 1 mm.

Conclusions: Our tension band wiring technique can be used regardless of the size of the dorsal fracture fragment or the interval between injury and surgery.