Upper Limb Injuries: Mallet Finger, Tendon & Nerve

Dr Jacqueline Tan

Senior Consultant Hand Surgeon

MBBS (SG) | MRCS (Edin) | MMed (Surgery) | FAMS (Hand Surgery)

Upper limb injuries can affect the functionality of the fingers, hands, wrists, and arms. Common examples include mallet finger or thumb and tendon or nerve injuries. These injuries, often caused by trauma or repetitive strain, can severely impair movement and daily activities if not promptly treated. Early diagnosis and appropriate care are necessary to avoid long-term complications.

Mallet Finger

Mallet finger or thumb is a deformity at the tip of the finger or thumb, where the affected area cannot straighten fully. This occurs when the tendon responsible for straightening the finger is torn or detached, often due to trauma, such as a direct blow or forceful bending of the fingertip. Severe cases may involve an avulsion fracture, where the force of the injury dislodges part of the bone.

Symptoms of Mallet Finger

Fingertip Drooping: The affected finger or thumb cannot straighten on its own and remains bent towards the palm.
Pain and Swelling: The injury site feels tender, swollen, and often painful, especially during attempts to straighten the fingertip.
Bruising or Discoloration: The injured area may turn purple or blue. In some cases, blood collects under the nail, causing it to detach partially or fully from the skin.
Reduced Functionality: Tasks like typing, gripping objects, or buttoning clothing become challenging due to limited range of motion.

Causes and Risk Factors

Direct Trauma: Mallet finger often results from sudden, forceful impacts on the extended fingertip, such as during ball sports or when the finger is jammed against a hard surface.
Minor Trauma: Everyday actions like bending the fingertip awkwardly during simple tasks can sometimes damage the tendon, especially in already weakened fingers.
Ageing or Degeneration: Over time, tendons may lose elasticity and strength due to ageing or conditions like rheumatoid arthritis, increasing the risk of injury.

Diagnostic Methods

Clinical Examination

The doctor evaluates the finger or thumb’s position, joint stability, and range of motion. They also check for associated injuries, such as nail bed damage, open wounds, or joint dislocations.

X-rays

Radiographic imaging is used to identify fractures, bone displacement, or avulsion fractures. X-rays also provide a clear view of joint alignment and the size of any displaced bone fragment, which helps guide treatment decisions.

Ultrasound Imaging

If fractures are not visible on X-rays, an ultrasound can assess the extent of soft tissue injuries. This includes detecting tendon tears, inflammation, or other damage to surrounding structures.

Treatment Options for Mallet Finger

Treatment for mallet finger depends on the severity of the injury, the presence of fractures, and how soon treatment is initiated.

Non-Surgical Treatment

Splinting

Splints keep the fingertip extended for 6–8 weeks, allowing the torn tendon to heal properly. After this period, patients use the splint at night for an additional 2–4 weeks to ensure stability. Splint care is necessary, and patients are instructed on how to replace the splint carefully without bending the finger.

Physical Therapy

Exercises introduced after splinting help restore strength, mobility, and coordination in the affected finger. A therapist supervises the rehabilitation process to prevent reinjury and ensure gradual progress.

Pain Management

Ice packs reduce swelling, while over-the-counter medications alleviate pain and discomfort during the healing phase.

Surgical Treatment

Internal Fixation

In cases of avulsion fractures, where bone fragments are displaced, pins or screws are used to secure the fragments and stabilise the joint. This technique ensures proper alignment and promotes healing of both the bone and tendon.

Tendon Repair

Severe or complex tendon tears may require surgical reattachment to the bone. Surgeons use sutures and specialised techniques to align the tendon, ensuring optimal function during recovery. Post-surgery splinting and physical therapy are required for a successful outcome.

Joint Reconstruction

In chronic cases, when injuries are left untreated or previous treatments fail, reconstructive surgery may be required. This procedure involves repairing or replacing damaged joint structures to restore mobility and prevent further complications, such as stiffness or deformity. Recovery from joint reconstruction may take longer and require intensive therapy.

Tendon and Nerve Injuries

Tendons control the bending and straightening of the fingers, hands, and wrists. These tissues are vulnerable to injuries from deep cuts or trauma, particularly on the flexor (palm side) and extensor (back side) surfaces of the hand. As nerves and blood vessels are often located near tendons, injuries can result in numbness, weakness, and reduced blood supply.

Symptoms of Tendon and Nerve Injuries

Movement Limitations: Inability to bend or straighten one or more joints in the affected hand or upper limb.
Pain: Sharp or aching pain, particularly when attempting to use the injured area.
Numbness and Tingling: Loss of sensation in areas supplied by the damaged nerve, often accompanied by tingling or “pins-and-needles” sensations.
Weakness: Difficulty gripping, lifting, or performing tasks that require strength in the hand or fingers.
Reduced Blood Flow: Pale or cold skin in the affected area may indicate compromised circulation.

Causes and Risk Factors

Deep Trauma: Lacerations from sharp objects or crush injuries can sever tendons, nerves, or both, leading to immediate loss of function.
Overuse Injuries: Repetitive motions, especially in occupational settings, may weaken tendons over time, resulting in partial tears.
Complicated Fractures: Fractures accompanied by tendon or nerve damage may occur in severe hand or forearm trauma.

Diagnostic Methods

Physical Examination

The surgeon evaluates finger strength and mobility by asking the patient to bend and straighten the injured area. Additional grip tests may be performed to assess the functionality of affected tendons and nerves.

Neurological Assessment

The extent of nerve damage is assessed by examining sensory responses, such as the ability to feel touch or pressure, and motor responses, including muscle strength and coordination in the affected area.

Imaging Studies

X-rays are used to detect associated bone fractures or dislocations. In cases involving suspected soft tissue damage, imaging techniques such as MRI or ultrasound provide detailed views of tendon tears, nerve injuries, or other structural damage.

Treatment Options for Tendon and Nerve Injuries

Treatment for tendon and nerve injuries depends on the severity of the damage, the structures involved, and the presence of any associated complications.

Non-Surgical Treatment

Splinting and Bracing

Partial tendon tears are stabilised using splints or braces to prevent further strain and allow the injured tissues to heal naturally. These devices immobilise the affected area, promoting proper alignment during recovery.

Physical Therapy

After initial treatment, post-injury therapy focuses on strengthening weakened muscles, improving hand mobility, and restoring dexterity. A customised rehabilitation plan is designed to help patients regain full use of their hand and prevent stiffness or loss of function.

Surgical Treatment

Tendon Reattachment

Severed tendons are surgically reconnected to restore their ability to control finger or hand movements. The procedure involves carefully suturing the ends of the tendon together and ensuring proper alignment to promote effective healing. Splints or braces are typically used post-surgery to support the repaired tendon during recovery.

Nerve Repair

Microsurgical techniques are used to repair damaged nerves. For severe injuries, nerve grafts may be required to bridge gaps where the nerve has been significantly damaged. This meticulous process aims to restore sensation, muscle control, and overall functionality in the affected area.

Combined Repairs

In complex cases where multiple structures, such as tendons, nerves, and blood vessels, are injured simultaneously, surgeons perform a single comprehensive procedure to address all damaged tissues. This integrated approach ensures optimal outcomes by treating the interconnected injuries efficiently.

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Prevention Strategies

To prevent mallet finger and tendon or nerve injuries, use protective gear like gloves or finger guards during sports or high-risk activities to shield fingers from trauma. Practise proper techniques to reduce impact, especially in ball sports or manual work.

In occupational settings, use ergonomic tools, maintain good hand posture, and take breaks to avoid repetitive strain. Keep workspaces free from hazards like sharp objects or heavy equipment. Handle sharp tools carefully and wear gloves when working with knives or machinery.

For those with arthritis or tendon weakness, strengthen hands with guided exercises and stretches. Regular hand care, including warm-ups before activities, can also help reduce injury risk.

Frequently Asked Questions

Can mallet finger recur after treatment?

Yes, mallet finger can recur if the tendon becomes weakened again due to repetitive strain, improper healing, or incomplete recovery. In such cases, additional treatment may be needed to restore function.

Can tendon or nerve injuries result in permanent disability?

Yes, severe tendon or nerve injuries can lead to permanent loss of function, sensation, or strength if not treated promptly or effectively. Early intervention and proper rehabilitation are necessary to minimise long-term complications.

How long does it take to regain full hand functionality after tendon surgery?

Regaining full hand functionality after tendon surgery typically takes 3–6 months. The recovery time depends on the severity of the injury, the effectiveness of rehabilitation efforts, and the individual’s natural healing ability.

Dr Jacqueline Tan

Senior Consultant Hand Surgeon

MBBS (SG)

MRCS (Edin)

MMed (Surgery)

FAMS (Hand Surgery)

Dr. Jacqueline Tan is a hand surgeon in Singapore with over 18 years of experience in managing hand, wrist, and nerve conditions. Formerly the Head of Department of Hand and Reconstructive Microsurgery at Singapore General Hospital, she has continued to contribute significantly to her profession.

Director of Micro-Reconstruction Service and the Director of Peripheral Nerve and Paralytic Upper Limb Service
Upon the completion of her training as a hand surgeon in Singapore, Dr Tan was awarded the prestigious Health Manpower Development Plan scholarship by the Ministry of Health (MOH).
Completed a one-year advanced fellowship in Taiwan under the tutelage of internationally-acclaimed Hand and Orthopedic Microsurgeon – Professor Yuan-Kun Tu
Dr Tan’s field of expertise is in early and late brachial plexus reconstruction, peripheral nerve disorders, reconstructive microsurgery of the extremities and wrist disorders.

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