Reply: Surgical Treatment Options for Unstable Mallet Fractures

Abstract

Sir: We would like to thank Lucchina et al. for their interest in our article entitled “Treatment Options for Mallet Finger: A Review.”1 Furthermore, we would like to compliment them on their work in which they retrospectively compared three different techniques for mallet fractures.2 Unfortunately, this study was published after the submission of our article and, therefore, had not been included in our review. In contrast to previous reports on the surgical treatment of mallet fractures, the study of Lucchina et al.2 compares three different techniques in a clinical setting. Based on their findings, they conclude that there is no statistically significant difference regarding the functional results of these techniques. Screw fixation is technically more demanding but allows earlier mobilization. Kirschner wire fixation with extension block pinning and techniques using Kirschner wires as joysticks are faster to perform and have fewer complications but require careful management of the pin tracks. However, we are of the opinion that although this study gives an indication about the treatment of mallet fractures involving more than one-third of the articular surface and palmar subluxation of the distal phalanx, it does not offer the required proof. In the first place, it only includes surgical treatments and no conservative treatment, despite the indications in the literature that this might be as effective.3 Other imperfections in the design are the retrospective nature of the study and the method of randomization. It is stated that “58 patients were randomly treated with one of the three surgical techniques by three surgeons.” However, it is not described how this randomization took place or what the considerations were to choose for one treatment. In conclusion, we are still of the opinion that controversy remains about whether mallet injuries with a larger dislocated bone fragment are best treated by surgery or by external splinting and that more randomized trials in a controlled setting should be performed to improve the treatment of mallet injuries. The recent study of Pike et al.,4 aimed at the conservative treatment of uncomplicated mallet fingers, is a good example of how such a study can be performed. Jeroen M. Smit, M.D. Michiel R. Beets, M.D. Clark J. Zeebregts, M.D., Ph.D. Akkie Rood, M.D. Carlo F. M Welters, M.D. University Medical Center Groningen Groningen, The Netherlands