Description
Mallet finger injuries occur when the tip of a finger or the thumb is forcefully bent. This condition is also known as baseball finger. It happens when a ball or other object strikes the tip of the digit. The force tears the thin tendon that allows you to straighten the finger. The force of the blow may even pull away a piece of bone along with the tendon.

Symptoms
A person with this injury has pain, swelling and bruising of the fingertip. The fingertip may droop noticeably. Occasionally, blood collects beneath the nail and the nail can even become detached from beneath the skin fold at the base of the nail.

Treatment Options
If you experience a mallet finger injury, immediately apply ice and elevate your hand above the level of your heart. Seek medical attention within the first week after this injury. It is very important to seek urgent attention if you have blood beneath the nail or if the nail is detached because you could also have a nail bed laceration or open (compound) fracture.

In most cases, the doctor will order X-rays to look for a major fracture or malalignment of the joint.

The majority of mallet finger injuries can be treated without surgery. The doctor may apply a splint to hold the fingertip straight (in extension) until it heals. Most of the time, you will have to wear the splint full-time for six weeks.

After six weeks, most patients gradually wean from the splint by wearing it less frequently over a three to four week period The finger usually regains acceptable function and appearance with this treatment plan; however, many patients may not regain full fingertip extension.

In children, mallet finger injuries may involve the cartilage that controls bone growth. A doctor must carefully evaluate and treat this type of injury, so the finger does not become stunted or deformed.

Treatment Options: Surgical

In certain cases, surgical repair may be considered. These cases include mallet finger injuries with:

• Large fracture fragments
• Joint malalignment

Surgical treatment in these cases often involves repair of the fracture using pins, pins and wire, or even small screws.

Surgery may also be considered if non-operative treatment fails. Repairing soft tissue mallet fingers is uncommon and usually reserved for patients with very severe deformities and functional problems. Surgical treatment can include tightening the stretched tendon tissue, using tendon grafts, or even fusing the joint straight. Consultation with an orthopaedic surgeon should be sought in these cases.

Bone is living tissue that requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die, a condition known as osteonecrosis. That’s what happens in Kienböck’s disease, which affects the lunate, one of the small bones of the hand near the wrist.

Kienböck’s Disease: Signs and Symptoms

The cause of Kienböck’s disease is unknown. Many people with Kienböck’s disease think they have a sprained wrist at first. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate. In most people, two vessels supply blood to the lunate, but in some people there is only one source. This puts them at greater risk for developing the disease.

As the disease progresses, other signs and symptoms are noted, including:

• A painful and sometimes swollen wrist
• Limited range of motion in the affected wrist (stiffness)
• Decreased grip strength in the hand
• Tenderness directly over the bone (on the top of the hand at about the middle of the wrist)
• Pain or difficulty in turning the hand upward

Progression

Kienböck’s disease follows a specific progressive pattern through four stages.

• Stage 1: Symptoms are similar to those of a wrist sprain. X-rays may be normal or show a line indicating a possible fracture. Magnetic resonance imaging (MRI) may also be helpful in making the diagnosis in this early stage.
• Stage 2: The lunate bone begins to harden. On an X-ray, it may appear brighter or whiter than the surrounding bones. These changes indicate that the bone is dying. Either an MRI or a computed tomography (CT) scan may be used to assess the condition of the bone. Recurrent pain, swelling and wrist tenderness are common.
• Stage 3: The dead bone begins to collapse and break into pieces. The surrounding bones may begin to shift position. Patients experience increasing pain, weakness in gripping, and limited motion.
• Stage 4: The surfaces of adjoining bones are affected, resulting in arthritis of the wrist.

Diagnosis and treatment
In its early stages, Kienböck’s disease may be difficult to diagnose because the symptoms are so similar to those of a sprained wrist. Even X-rays of the wrist may appear normal. At this point, the goal of treatment is to relieve the pressure on the lunate and help restore blood flow within the bone. Your physician may splint or cast your wrist for two to three weeks.

Anti-inflammatory medications such as aspirin or ibuprofen will help relieve any pain and reduce swelling. If the pain continues, your physician may refer you to an orthopaedic or hand surgeon for further evaluation.

Surgical options
Although there is no cure, there are several surgical options for treating the more advanced stages of Kienböck’s disease. The right procedure for you will depend on several factors, including disease progression, your personal activity levels and goals and your surgeon’s experience with various procedures.

Do not hesitate to discuss these options with your orthopaedic or hand surgeon and to ask why he or she is recommending a particular procedure.

In some cases, returning the blood supply to the bone (revascularization) may be possible. This procedure uses a bone graft from the inner bone of the lower arm. It may be combined with an external fixator, a metal device that helps relieve pressure on the lunate and preserve the spacing between bones.

If the bones of the lower arm are uneven in length, a joint leveling procedure may be recommended. Bones can be made longer with bone grafts, or shortened by removing a section of the bone.

This reduces the compressive forces on the lunate and seems to halt progression of the disease. If the lunate is severely collapsed or fragmented, it can be removed. The two bones on either side of it are also removed. This procedure is called a proximal row carpectomy and will relieve pain while maintaining partial wrist motion.

Another way to ease pressure on the bone is to fuse several of the small bones of the hand together. However, this will not improve range of motion. If the disease has progressed to severe arthritis of the wrist, fusing the bones will reduce pain and help maintain function, although motion is limited.

Our hands serve many purposes. Hands help us eat, dress, write, earn a living, create art and do many other activities. To accomplish these tasks and activities, our hands require sensation and movement, such as joint motion, tendon gliding and muscle contraction.

When a problem takes place in the hand, care must be given to all the different types of tissues that make function of the hand possible.

Hand surgeons are specifically trained to give that care:

• Hand surgery is the field of medicine that deals with problems of the hand, wrist and forearm.
• Hand surgeons care for these problems without surgery, and they are specially trained to operate when necessary.
• Many hand surgeons are also experts in diagnosing and caring for shoulder and elbow problems.
• Hand surgeons are orthopedic, plastic or general surgeons who have additional training in surgery of the hand.
• To become a member of the American Society for Surgery of the Hand, a hand surgeon must complete a full year of additional training and must pass a rigorous certifying examination.