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ILLUSTRATIVE CASE
Mallet Finger in a Toddler
A Rare But Easily Missed Injury
Karen E. Forward, MD, FRCPC,* Arjang Yazdani, MD, FRCSC,† and Rodrick Lim, MD, FRCPC, FAAP*‡§
Abstract: A mallet finger is a flexion deformity of a finger at the distal
interphalangeal joint due to an injury of the extensor mechanism at the base
of the distal phalanx. Most common in middle-aged men, injuries in the pediatric population are less common and rare in toddlers. We describe a case
of missed mallet finger and its subsequent treatment in a female toddler.
Key Words: mallet finger, toddler, hand injuries
(Pediatr Emer Care 2017;33: e103–e104)
U
nlike in adult patients, where mallet finger deformities result
from an injury or laceration to the extensor tendon of a digit
with or without an associated fracture,1 in skeletally immature
children, this injury typically occurs as a result of an avulsion fracture of the distal phalangeal epiphysis—the insertion point of a
digit's extensor tendon.2 In young children, delayed diagnosis of
this injury type is common,2,3 – likely because of the rarity of this
injury in toddlers and the fact that functional impairment often is
not immediately noted. Although this injury is rare, we describe
here a case of missed mallet finger and its subsequent treatment
in a female toddler.
CASE
A 2-year-old girl presented to the pediatric emergency department with an injury to her right small finger. She had reportedly injured her fifth finger by crushing it in a bedroom door.
On her initial examination, she had some abrasions to her finger,
with bruising noted over the volar aspect of her finger. A radiograph was performed and its result was reported to be normal
(Fig. 1). She was treated conservatively with buddy taping and
told to follow up with her family doctor. One week later, she returned to the pediatric emergency department for reassessment because her parents noted that she continued not to use her finger.
On physical examination, she was unable to extend the distal interphalangeal (DIP) joint of her fifth finger (Fig. 2). Because the con-
FIGURE 1. Initial radiograph.
From the *Department of Paediatrics, †Division of Plastic Surgery, Department
of Surgery, and ‡Division of Emergency Medicine, Department of Medicine,
Schulich School of Medicine at Western University; and §Children's Health
Research Institute, at the Children's Hospital at London Health Sciences Centre,
London, Ontario, Canada.
Disclosure: The authors declare no conflict of interest.
Reprints: Rodrick Lim, MD, FRCPC, FAAP, Children's Hospital at London
Health Sciences Centre, 800 Commissioners Road East, London, ON,
Canada N6C 2V5 (e‐mail: Rod.Lim@lhsc.on.ca).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
ventional splints in the pediatric emergency department were not
sufficiently small, plastic surgery was consulted and a small custom splint was fashioned by an occupational therapist (Fig. 3).
The toddler followed up with plastic surgery and, with persistent
splinting for 6 weeks, obtained full extension once again.
DISCUSSION
Mallet fingers are a prevalent adult injury most commonly
seen in middle-aged men or older women.4 Fingertip injuries are
Pediatric Emergency Care • Volume 33, Number 10, October 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
www.pec-online.com
e103
Pediatric Emergency Care • Volume 33, Number 10, October 2017
Forward et al
In terms of causation, in the very young, congenital causes
for mallet finger should also be considered in the differential
(eg, congenital extensor tendon deficiency)5; however, in the setting of trauma, hyperflexion is the commonest cause of mallet finger injury in the skeletally immature.6 Other potential causes
include tumors (soft or bony) and “mimics” of mallet finger—
such as fractures to the distal phalanx, which also may present
with a “bent” DIP joint.5
Mallet fingers are described using a classification scheme
(I through IV) developed by Doyle.4 Type I injuries are closed injuries to the extensor tendon that may/may not involve a small
avulsion fracture. Type II and III injuries involve a laceration
and are open, but type III fractures are deep. Finally, type IV fractures are subdivided into 3 groups: A, distal phalanx physeal injuries (pediatrics); B, fractures involving 20% to 50% of the articular
surface (adults); and C, fractures involving greater than 50% of
the articular surface (adult). Most mallet fingers to pediatric patients will therefore be classified as IV-A.4
Treatment for mallet fingers may be conservative (eg,
splinting) or operative,1 and generally, surgical measures are only
considered when conventional treatments fail.2 A 2004 Cochrane
review looked at the efficacy of off-the-shelf aluminum splints vs
custom splints in predominately adult patients and found insufficient evidence to recommend one measure over another—but
stressed the importance of compliance and durability with any
splint applied.7 In our toddler, whose finger was too small for
an off-the-shelf splint, custom splints provided a comfortable alternative and achieved the desired results with constant daily use.
FIGURE 2. Picture of the fifth digit.
CONCLUSIONS
Although extremely rare, mallet fingers can occur in toddlers
and young children after seemingly minor trauma. They are often
missed on initial presentation and are frequently but not always associated with an avulsion fracture the distal phalangeal epiphysis.
It is important for the clinician to be vigilant to look for this injury
because it can be easily clinically missed in the very young. Once
diagnosed, they can typically be treated conservatively with a
well-fitted splint for 6 to 8 weeks and close follow-up.
REFERENCES
1. Schmidt B, Weinberg A, Friedrich H. The mallet finger in children and
adolescents [in German]. Handchir Mikrochir Plast Chir. 2008;40:149–152.
FIGURE 3. Custom splint.
common in children, and a mallet finger can be seen, caused by a
disruption of the extensor tendon mechanism in the region of the
DIP joint in an open epiphyseal plate.2 In a 10-year review of pediatric mallet finger, the average age was 11.3 years.1 Although
they are extremely rare injuries to see in the toddler age, there have
been a handful of mallet finger injuries described in children as
young as 1 year in the orthopedic literature.1,2
In the very young, the examination of the hand can prove to
be difficult. The patients are often noncompliant, fearful, and unable to follow specific instructions. Because of the nature of this
injury, it is important to be thorough in the assessment of the affected finger, because the diagnosis can be easily missed.
e104
www.pec-online.com
2. Kardestuncer T, Bae DS, Waters PM. The results of tenodermodesis for
severe chronic mallet finger deformity in children. J Pediatr Orthop. 2008;
28:81–85.
3. Shin EK, Bae DS. Tenodermodesis for chronic mallet finger deformities in
children. Tech Hand Up Extrem Surg. 2007;11:262–265.
4. Bendre A, Hartigan B, Kalainov D. Mallet finger. J Am Acad Orthop Surg.
2005;13:336–344.
5. Ganayem M, Edelson G. Base of distal phalanx fracture in children: a mallet
finger mimic. J Pediatr Orthop. 2005;25:487–489.
6. Walshaw L. Practical procedures for minor injuries: mallet splint. Accid
Emerg Nurs. 2004;12:182–184.
7. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries.
Cochrane Database Syst Rev. 2004:CD004574.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
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