Investigation of the conservative management of mallet injury in Irish acute hospitals

Abstract

Introduction. Mallet injury is a commonly treated hand injury in acute hospitals. While there is much literature regarding the various treatment options and outcomes, no studies were found that describe the management of this injury across a national health service. This study describes how mallet injury is managed within the acute hospital system in Ireland. An understanding of the current system of service provision is essential for future service development in this area. Method. Emergency and occupational therapy departments in the 29 acute case-mix hospitals in Ireland were contacted by telephone and postal questionnaire with 47 respondents participating in the study. Descriptive statistics are used to present the results. Results. Results indicate that accessing acute hospital-based services for the conservative management of mallet injury typically follows a predictable pathway, but can result in delays and disruption to treatment for the patient. There is little evidence of direct referral from the emergency department to the occupational therapist which, when compared with published literature, would represent the most efficient and optimum care pathway for the patient. The choice of splint used by both the emergency and occupational therapy departments differs, but treatment provided is in line with available evidence-based practice.Conclusions. This preliminary study provides a basis for future service development in the acute management of mallet injury, by describing how treatment is currently provided nationally. Recommendations for further investigation have been made, and the need for audit and outcome measurement has been highlighted. The development of therapy-led services in Ireland is proposed, to improve efficiency and quality of service provision in the conservative management of mallet injury.

How do hand therapists conservatively manage acute, closed mallet finger? A survey of members of the British Association of Hand Therapists

“…Custom thermoplastic splinting was considered the preferential means of DIPJ immobilisation. The practice of six to eight weeks continuous immobilisation was observed; six weeks for bony and eight weeks for tendinous injury (72% respondents), as is consistent with other survey evidence 31 and appropriate healing times. 49–54 Despite the questionable efficacy of a splint weaning period, 46 it was often seen as clinically necessary by respondents and influenced by individual presentation and functional demand.…”

“…3,19 However, custom splinting has been shown to permit a more appropriate and comfortable fit and potentially fewer skin complications 2,25–27 and was the favoured splinting option by respondents (Figure 2). Clinical and biomechanical literature proposes PIPJ exclusion during immobilisation 2,26–29,31,43–45 and findings of this research confirm this practice. Furthermore, therapists reported their ability to tailor splint design and exercise in order to prevent and manage subsequent complications.…”

“…The best evidence of the highest scientific value therefore demonstrates a period of splint immobilisation to constitute the conservative management of acute, closed mallet finger. A previous survey on practices within acute hospitals in Ireland 31 verified the existence of care pathways in line with available evidence-based splinting practice for this population. However, the authors concluded that there was little evidence to suggest that specialist hand therapist intervention was being utilised in a timely or effective manner.…”

“…Questions were based on salient themes, which emerged from the literature review and prior study. 31 Topics covered splint type and position, duration of wear, the application of any splint weaning phase, supplementary rehabilitation and specific exercise prescription and/or avoidance. A participant information sheet was also provided, assuring anonymity, confidentiality and rights to withdrawal in accordance with ethical requirements.…”

“…Although 81% (26) respondents reported a six-to eight-week splinting period (Figure 3), only 72% (23) defined this to be six weeks for bony mallets and eight weeks for tendinous injury. Previous research 2,19,25,26,31 suggests continuous six-to eight-week splinting, with night splinting until 12 weeks post presentation; whether tendinous or with bony involvement. Support of a splint weaning period post-immobilisation is lacking within high-level clinical evidence, 2,26,46 yet all respondents indicated this to be their standard practice, with 81% recommending a period of up to four weeks.…”