Conservative management of mallet injuries: A national survey of current practice in the UK

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Summary

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 unclear whether this uncertainty is reflected in current UK practice.

Methods

An online survey was developed to determine the current practice for the conservative treatment of mallet injury among specialist hand clinicians in the UK, including physiotherapists, occupational therapists and surgeons. Clinician's views of study outcome selection were also explored to improve future trials.

Results

In total, 336 professionals completed the survey. Inconsistency in overall practice was observed in splint type choice, time to discharge to GP, and assessment of adherence. Greater consistency was observed for recommended duration of continuous immobilisation. Bony injuries were most commonly splinted for 6 weeks (n = 228, 78%) and soft tissue injuries for either 8 weeks (n = 172, 56%) or 6 weeks (n = 119, 39%). Post-immobilisation splinting was frequently recommended, but duration varied between 2 and 10 weeks. The outcome rated as most important by all clinicians was patient satisfaction.

Discussion

There is overall variation in the current UK conservative management of mallet injuries, and the development of a standardised, evidence-based protocol is required. Clinicians' opinions may be used to develop a core set of outcome measures, which will improve standardisation and comparability of future trials.

Introduction

Mallet finger, or thumb, is a common traumatic injury to the hand.1 Mallet injuries result from disruption of the extensor tendon mechanism at the distal interphalangeal joint (interphalangeal joint of the thumb) either due to tendon rupture (a soft tissue mallet) or avulsion (a bony mallet) leading to the inability to extend the distal interphalangeal joint.2 If untreated, a mallet injury may become chronic leading to a swan neck deformity of the finger. As approximately two-thirds of mallet injuries affect the dominant hand,3 effective treatment is important to avoid compromising long-term hand function. In the UK, most patients are first seen in the accident and emergency department. A proportion may require surgical intervention, and therefore the majority are subsequently referred to regional hand units or orthopaedic fracture clinics, depending on local protocol. If patients do not require surgery and can be treated in a splint, they are usually referred to the hand therapists for further management. There is great variation in the UK, depending on local resources. Where specialist hand physiotherapy or occupational therapy involvement occurs, it is usually after the surgical decision of conservative management. However, some units may have a pathway, whereby patients without fractures are directed straight to a therapist.

Immobilisation with a splint is the most common conservative treatment for undisplaced, closed bony and closed soft tissue mallet injuries, but there is a lack of consensus regarding the duration of immobilisation4 and the type of splint used.3, 4, 5, 6 There is also a lack of agreement regarding appropriate outcome measurements.1 Randomised trials are considered the best evidence for determining the effectiveness of an intervention, but several systematic reviews have demonstrated a lack of well-designed and reported trials in mallet finger.3, 4, 6 A well-designed large-scale RCT is therefore required to determine the optimum conservative management of mallet injury. Designing such a trial requires feasibility work to understand current practice and to determine the most appropriate outcome measures. A survey of clinicians in the UK to determine current practices and whether they reflect the lack of consensus apparent in the literature was performed. Clinicians' views of outcome measures were sought to facilitate the development of a core outcome set to improve robustness of future trials.

Section snippets

Methods

An online survey was developed by the study team, including a senior hand therapist, consultant hand surgeons and experienced health services methodologists (Appendix 1). Using specialist knowledge and a review of the literature, the study team defined the concepts to be measured, which included the use of treatment protocols, durations of continuous protective (or intermittent) immobilisation, types of splint used, time to discharge to GP, assessment of adherence to treatment and outcomes of

Results

A total of 372 survey responses were received. Of these, 4 were blank; 26 were completed by surgeons below consultant level, and 7 were completed by professionals who could not be classified into an appropriate respondent group (e.g. cross-speciality hand therapists). These records were excluded. A total of 336 surveys were included in the analysis because of the anonymisation of the survey and crossover of membership between professional groups, a response rate is not presented.

The 336 survey

Discussion

There is no consensus regarding the optimal conservative management of mallet finger in the UK and limited high quality evidence to support the best practice. This national survey reflects the variation in the literature regarding the conservative management of mallet finger including recommended duration of protection immobilisation, time to discharge to GP, assessment of adherence to treatment and type of splint. Several systematic reviews including a Cochrane review have highlighted a lack

Conclusion

Our findings demonstrate an overall lack of consensus in the current conservative management of mallet injury in the UK, indicating a requirement for the development of a standardised, evidence-based treatment protocol. Qualitative approaches, such as interviews or focus groups, to further explore the reasons for differing practices between the therapeutic and surgical specialities would represent a valuable part of this development. Important preliminary work towards the development of a core

Conflicts of interest

None.

Acknowledgements

This work was funded by a pump-priming grant from the British Association of Plastic, Reconstructive and Aesthetic Surgeons and the British Society for Surgery of the Hand. The study sponsors had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript or in the decision to submit the manuscript for publication.

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