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American Association for Hand Surgery

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Nonoperative management of bony mallet injuries in the pediatric patient population
Jennifer Kargel, MD, Plastic Surgery, Division of Hand Surgery, University of Texas Southwestern, Dallas, TX and Jonathan Cheng, MD, Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX

Introduction:Mallet injuries are most commonly treated nonoperatively with surgical indications traditionally reserved for injuries that involve articular fractures of the distal phalanx greater than 30 to 40 percent of the joint surface and with joint subluxation. In our pediatric population, we have successfully treated the majority of our bony mallet injures nonoperatively with a combination of splinting and casting, as well as close follow-up to ensure bony union and joint alignment.
Materials and Methods:A retrospective review was performed of all pediatric patients that presented to the authors' practice at a single institution with distal phalanx base fractures and associated extensor lag (ie bony mallet) over an 11 year period. Information analyzed included patient demographics, degree of bony involvement, presence of instability, and length of treatment in those treated nonoperatively. Outcomes reviewed including presence and degree of residual extensor lag, evidence of bony union on plain films, and patient-reported functional capability of the digit post-treatment.
Results:A total of 40 patients with 42 involved fingers were identified. Of these, 7 were excluded due to concomitant injuries of the same digit and/or no follow-up after initial presentation. Of the remaining 35 fingers included, 83% were treated nonoperatively (29=nonoperatively, 6=closed versus open reduction and pinning). The average age of patient was 13.9 years old (ages=10-18 years old), and the majority were right-hand dominant (91%). Time from injury to evaluation/treatment was on average 21+/- 26.4 days. In non-operative patients, continuous splinting was performed for an average of 5.4+/- 1.2 weeks. Average percent of articular involvement of the fracture was 44.7%. In 5 of the 6 operative cases, subluxation was noted. In all of the non-operative cases, no subluxation was noted. At follow-up, only 3 patients had non-union, two of which were due to small dorsal avulsion fractures <20% of the joint surface. All patients had noted return to regular activities with reported mild to no residual stiffness.
Conclusions:In our pediatric patient population, satisfactory functional results are obtainable with nonoperative treatment of bony mallet injuries, including those with greater than 30 to 40 percent joint surface involvement.


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