The treatment options for the soft-tissue mallet finger, in both its acute and chronic forms, continue to generate some degree of controversy. Priority always should be given to nonoperative management of these injuries. This translates into a 6- to 8-week period of uninterrupted immobilization of the DIP joint with an external splint. Splinting has been shown to be highly effective, safe, and reproducible for both acute and chronic lesions. Even in the presence of an open injury, the value of splinting must be appreciated by the practitioner. The conversion of an acute closed soft-tissue injury to an open one is to be discouraged because of unacceptable complication rates. When surgery is contemplated, our first option would be the placement of a transarticular Kirschner wire at the DIP joint.

If external splinting fails in an acute injury, an argument certainly can be made for a second trial of conservative management, and we offer this alternative to such patients. We find that some patients will not tolerate a second period of immobilization, and in most cases, we offer surgery in these failed cases. Surgical choice, again, would be a transarticular Kirschner wire. Another choice would be one of the salvage procedures, such as central slip tenotomy, with the expectation of a good result.

In summary, mallet injuries are treated using closed, nonoperative techniques. The period of time after injury that this nonoperative treatment can be delayed and still be effective is being extended and the absolute outside time limit still is not known.

When surgery is done, we prefer the simple placement of a transarticular Kirschner wire for 6 to 8 weeks. The outside time limit is not known for this treatment, either. Selection for this technique depends mainly on the patient’s occupation. Salvage procedures to be considered for late cases include the Fowler procedure or oblique retinacular ligament reconstruction.