EXTENSOR TENDON INJURY AT THE FINGERTIP
The drooping fingertip that cannot straighten. Often treated without surgery — but only if the splint protocol is followed strictly, without exception, for six to eight continuous weeks.
ABOUT THIS INJURY
Mallet finger occurs when the fingertip is forcibly bent downward against an extended finger — typically when a ball strikes the tip, or when the finger catches on something and is acutely hyperflexed. The extensor tendon, which is responsible for lifting the fingertip, either ruptures or pulls a fragment of bone away from its attachment. The result is a fingertip that droops and cannot be actively straightened.
The first line of treatment is not surgery — it is continuous splinting. A mallet splint holds the distal joint in extension and must be worn at all times, day and night, for six to eight weeks to allow the tendon or bone fragment to heal. Removing the splint even once resets the healing process. In many cases, strict compliance with this protocol achieves a full recovery without surgery.
Surgery is indicated when splinting fails, when the bony fragment is large or significantly displaced, or when the joint becomes unstable. Surgical options include direct tendon repair through a small incision or the passage of two metal wires through the bones to hold the joint straight while healing occurs. Post-operative immobilisation is just as essential after surgery as in non-operative management.
SAME DROOP, DIFFERENT INJURY
Tendinous mallet finger occurs when the extensor tendon ruptures at the level of the distal joint without pulling away any bone. The tendon simply tears. An X-ray will appear normal. Treatment is continuous splinting for six to eight weeks, which allows the tendon ends to heal together with the joint held in full extension.
Bony mallet finger occurs when the extensor tendon avulses a fragment of bone from the distal phalanx as it tears away. This is visible on X-ray. Small fragments are still managed with splinting; larger fragments involving more than a third of the joint surface — or those causing joint subluxation — are more likely to require surgical fixation.
Both types present with a drooping, un-liftable fingertip
X-ray is essential to distinguish type and guide treatment
Tendinous type: splinting alone is the standard treatment
Bony type: splinting is usual; surgery if fragment is large or joint unstable
Fragment >1/3 of joint surface: surgical fixation often recommended
Both types require strict immobilisation whether treated surgically or not
Recovery timeline is six to eight weeks for both types
Physiotherapy after splinting improves final extension strength
THE PROCEDURE AT A GLANCE
For cases where splinting alone is insufficient.
Surgery Time
Anaesthesia
Hospital Stay
Drains
Supporting Garment
The exact surgical approach — augmentation, reduction, lift or combination — is determined at consultation based on your individual anatomy and goals.
RECOVERY TIMELINE
Week 1
A mallet splint is applied holding the distal joint in full extension. If surgery was performed, the first follow-up checks wound healing and confirms correct wire or repair position.
Weeks 2–4
The splint must be worn at all times. No exceptions. Even a momentary flex of the fingertip during this phase can disrupt healing and restart the clock. Compliance is everything.
Weeks 4–6
Return to sedentary or light work is typically possible from week four — with the splint in place. Work requiring full use of the hand or removal of the splint must wait until healing is confirmed.
Months 2–3
Once the splint is safely discontinued, physiotherapy begins to restore full extension strength and prevent the slight residual droop that can persist without targeted rehabilitation.
WHAT CORRECT TREATMENT ACHIEVES
When the splint protocol is followed without deviation — or when surgery is appropriately performed — most patients achieve a functional and cosmetically acceptable result.
WHY GETTING THIS RIGHT MATTERS
Distinguishing a tendinous mallet from a bony mallet on X-ray determines the initial management strategy. An incorrect classification leads to the wrong treatment and a preventable poor outcome.
Patients who understand why the splint cannot be removed — even briefly — are far more likely to complete the protocol successfully. Clear guidance from the outset prevents the most common cause of treatment failure.
When non-operative management is not appropriate or has failed, surgical options are available to reattach the tendon or stabilise the bony fragment — performed under local anaesthesia as a day case.
Once splinting ends, targeted physiotherapy helps recover full extension power and prevent the residual droop that can otherwise become a permanent fixture of an untreated or under-rehabilitated finger.
STRICT MEANS STRICT
The extensor tendon heals by scar tissue formation at the tear site. For scar tissue to bridge the gap and fuse the tendon ends, the joint must be held in a position where the gap is at its minimum — full extension — without interruption for the entire healing period.
Every time the splint is removed and the finger droops, the gap reopens, the immature scar tissue tears, and the healing process must begin from scratch. This is not a guideline — it is biology. Patients who understand the mechanism almost always comply. Those who think they can remove the splint “just to wash’ almost always end up needing surgery that could have been avoided.
“
I caught my finger on the net playing volleyball. The splint felt like an inconvenience at first but I wore it without fail for eight weeks. My finger is completely straight now.
“
I came in late after trying to manage it at home. Professor Hindocha explained the surgical options clearly and the wires did their job. I wish I’d come in sooner.
“
Six weeks felt like a long time but the physio at the end made all the difference to getting full lift back. I’m back playing cricket with no restrictions at all.
DO YOU NEED SURGERY?
Most mallet fingers are managed without surgery. Surgical intervention is recommended in specific circumstances — particularly when the injury pattern or patient factors make splinting unlikely to succeed:
WHEN THE SPLINT IS NOT ENOUGH
When splinting alone is not appropriate — due to injury severity, failed conservative treatment, or patient factors — surgery offers two well-established approaches to restoring extension at the fingertip.
Open tendon repair involves a small incision over the dorsum of the finger to directly reattach the extensor tendon to the bone. This is preferred for purely tendinous injuries where direct repair is achievable.
Kirschner wire fixation involves passing two metal wires through the bones to hold the distal joint in full extension while the tendon or bone fragment heals. The wires sit beneath the skin surface and are removed in clinic once healing is confirmed, typically at six to eight weeks. No incision over the tendon is required.
WHEN SURGERY IS INDICATED
RELATED HAND INJURIES
Specialist hand and finger trauma managed at the same clinic.
HAND SURGERY
Flexor tendon avulsion at the fingertip — the counterpart to mallet finger on the palm side of the hand.
HAND SURGERY
Broader tendon lacerations and ruptures in the hand and forearm requiring surgical repair.
HAND SURGERY
Displaced or unstable fractures of the hand and finger bones requiring surgical fixation.
DON'T LET YOUR FINGER SET WRONG
Correct treatment from day one matters.
Whether your mallet finger is a fresh injury or one that has been left untreated for weeks, an early specialist assessment will establish the correct diagnosis, determine the appropriate management, and give you the best chance of a full recovery. Mallet fingers left to heal in the wrong position become significantly harder to correct.
FREQUENTLY ASKED QUESTIONS
What patients ask us most about this injury.
