Review article (meta-analysis)| Volume 96, ISSUE 10, P1913-1923.e1, October 2015

Custom-Made Finger Orthoses Have Fewer Skin Complications Than Prefabricated Finger Orthoses in the Management of Mallet Injury: A Systematic Review and Meta-Analysis



      To investigate which orthosis results in (1) fewer complications; (2) the least extensor lag; and (3) the highest rates of treatment success according to the Abouna and Brown criteria for soft tissue mallet injury in adults.

      Data Sources

      Electronic databases AMED, CINAHL, Embase, MEDLINE, PubMed, OTseeker, and PEDro were searched from the earliest available date until September 16, 2014.

      Study Selection

      Controlled trials evaluating orthosis type in the conservative management of mallet injury were included. Database searching yielded 1024 potential studies, of which 7 met inclusion criteria with a total of 491 participants.

      Data Extraction

      Data were extracted using an author-designed extraction form by one reviewer, and accuracy was assessed by a second reviewer. The PEDro scale was used to assess methodological quality.

      Data Synthesis

      Results were pooled using a random-effects model with inverse variance methods. Dichotomous outcomes are expressed as risk ratios (RRs) and 95% confidence intervals (CIs) and continuous outcomes as standardized mean differences and 95% CIs. There is moderate quality evidence that prefabricated orthoses had 3 times the risk of developing skin complications as compared with all other orthoses (RR, 3.17; 95% CI, 1.19–8.43; I2=47%) and nearly 7 times the risk of developing skin complications as compared with custom-made thermoplastic orthoses (RR, 6.72; 95% CI, 1.59–28.46; I2=0%). Treatment outcomes were found to be similar for treatment success when prefabricated orthoses were compared with custom-made orthoses (RR, .99; 95% CI, 0.80–1.22; I2=39%; very low quality evidence), as well as for extensor lag when custom-made thermoplastic orthoses were compared with other orthoses (standardized mean difference, .03; 95% CI, −.29 to .36; I2=0%; moderate quality evidence).


      Prefabricated orthoses were found to increase the risk of developing skin complications as compared with custom-made orthoses, but there were no differences in treatment success, failure, or extensor lag.


      List of abbreviations:

      CI (confidence interval), DIP (distal interphalangeal), PIP (proximal interphalangeal), RCT (randomized controlled trial), RR (risk ratio), SMD (standardized mean difference), VAS (visual analog scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Haagsma A.
        • deBoer H.L.
        • Quintus A.C.
        • Strikkeling N.J.
        • Zeebregts C.J.
        • Smit J.M.
        Treatment of mallet fingers in Dutch hospitals: a nationwide survey of practice.
        Eur J Emerg Med. 2015; 22: 211-214
        • Bendre A.A.
        • Hartigan B.J.
        • Kalainov D.M.
        Mallet finger.
        J Am Acad Orthop Surg. 2005; 13: 336-344
        • Garberman S.F.
        • Diao E.
        • Peimer C.A.
        Mallet finger: results of early versus delayed closed treatment.
        J Hand Surg. 1994; 19: 850-852
        • Stack G.
        Mallet finger.
        Lancet. 1968; 2: 1303
        • Geyman J.
        • Fink K.
        • Sullivan S.
        Conservative versus surgical treatment of mallet finger: a pooled quantitative literature evaluation.
        J Am Board Fam Pract. 1998; 11: 382-390
        • Alla S.R.
        • Deal N.D.
        • Dempsey I.J.
        Current concepts: mallet finger.
        Hand. 2014; 9: 138-144
        • Bloom J.M.
        • Khouri J.S.
        • Hammert W.C.
        Current concepts in the evaluation and treatment of mallet finger injury.
        Plast Reconstr Surg. 2013; 132: 560e-566e
        • Stack H.G.
        Mallet finger.
        Hand. 1969; 1: 83-89
        • Cheung J.P.
        • Fung B.
        • Ip W.Y.
        Review on mallet finger treatment.
        Hand Surg. 2012; 17: 439-447
        • Gruber J.S.
        • Bot A.G.
        • Ring D.
        A prospective randomized controlled trial comparing night splinting with no splinting after treatment of mallet finger.
        Hand. 2014; 9: 145-150
        • Smit J.M.
        • Beets M.R.
        • Zeetbregts C.J.
        • Rood A.
        • Welters C.F.
        Treatment options for mallet finger: a review.
        Plast Reconstr Surg. 2010; 126: 1624-1629
        • Di Paola M.
        Mallet finger.
        Practitioner. 1986; 230: 187-189
        • Altan E.
        • Alp N.B.
        • Baser R.
        • Yalcin L.
        Soft-tissue mallet injuries: a comparison of early and delayed treatment.
        J Hand Surg. 2014; 39: 1982-1985
        • Maitra A.
        • Dorani B.
        The conservative treatment of mallet finger with a simple splint: a case report.
        Arch Emerg Med. 1993; 10: 244-248
        • Auchincloss J.M.
        Mallet-finger injuries: a prospective, controlled trial of internal and external splintage.
        Hand. 1982; 14: 168-173
        • Okafor B.
        • Mbubaegbu C.
        • Munshi I.
        • Williams D.J.
        Mallet deformity of the finger: five-year follow-up of conservative treatment.
        J Bone Joint Surg Br. 1997; 79: 544-547
        • Warren R.A.
        • Kay N.R.
        • Ferguson D.G.
        Mallet finger: comparison between operative and conservative management in those cases failing to be cured by splintage.
        J Hand Surg Br. 1988; 13: 159-160
        • Leinberry C.
        Mallet finger injuries.
        J Hand Surg. 2009; 34: 1715-1717
        • Lester B.
        • Jeong G.K.
        • Perry D.
        • Spero L.
        A simple effective splinting technique for the mallet finger.
        Am J Orthop. 2000; 29: 202-206
        • Stern P.J.
        • Kastrup J.J.
        Complications and prognosis of treatment of mallet finger.
        J Hand Surg. 1988; 13: 329-334
        • Pratt D.R.
        • Bunnell S.
        • Howard Jr., L.D.
        Mallet finger: classification and methods of treatment.
        Am J Surg. 1957; 93 (discussion 578-9): 573-578
        • Katsoulis E.
        • Rees K.
        • Warwick D.J.
        Hand therapist-led management of mallet finger.
        Br J Hand Ther. 2005; 10: 17-20
        • Rayan G.M.
        • Mullins P.T.
        Skin necrosis complicating mallet finger splinting and vascularity of the distal interphalangeal joint overlying skin.
        J Hand Surg. 1987; 12: 548-552
        • Cederlund R.
        • Kul F.
        • Rouzaund J.C.
        • Wendling-Hosch U.
        • Ausheim T.
        • Schreuders T.
        Results of Delphi round in mallet finger for EFHST consensus.
        European Federation of Societies for Hand Therapy, Delphi2008
        • Wilson S.W.
        • Khoo C.T.
        The Mexican hat splint—a new splint for the treatment of closed mallet finger.
        J Hand Surg Br. 2001; 26: 488-489
        • Handoll H.H.
        • Vaghela M.V.
        Interventions for treating mallet finger injuries.
        Cochrane Database Syst Rev. 2004; : CD004574
        • O’Brien L.J.
        • Bailey M.J.
        Single blind, prospective, randomized controlled trial comparing dorsal aluminum and custom thermoplastic splints to stack splint for acute mallet finger.
        Arch Phys Med Rehabil. 2011; 92: 191-198
        • Pike J.
        • Mulpuri K.
        • Metzger M.
        • Ng G.
        • Wells N.
        • Goetz T.
        Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger.
        J Hand Surg. 2010; 35: 580-588
        • Tocco S.
        • Boccolari P.
        • Landi A.
        • et al.
        Effectiveness of cast immobilization in comparison to the gold-standard self-removal orthotic intervention for closed mallet fingers: a randomized clinical trial.
        J Hand Ther. 2013; 26: 191-201
        • Pratt A.L.
        Is eight weeks’ immobilisation of the distal interphalangeal joint adequate treatment for acute closed mallet finger injuries of the hand? A critical review of the literature.
        Br J Hand Ther. 2004; 9: 4-10
        • de Morton N.
        The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
        Aust J Physiother. 2009; 55: 129-133
        • Abouna J.M.
        • Brown H.
        The treatment of mallet finger: the results in a series of 148 consecutive cases and a review of the literature.
        Br J Surg. 1968; 55: 653-667
        • Higgins J.
        • Green S.
        The Cochrane handbook for systematic reviews of interventions. Version 5.1.0.
        The Cochrane Collaboration, London2011 (Available at:) (Accessed November 10, 2014)
        • Higgins J.
        • Thompson S.
        • Deeks J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        Br Med J. 2003; 327: 557-560
        • Guyatt G.
        • Oxmanm A.D.
        • Akl E.A.
        • et al.
        [GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables].
        J Clin Epidemiol. 2011; 64 ([German]): 383-394
        • Kinninmonth A.W.
        • Holburn F.
        A comparative controlled trial of a new perforated splint and a traditional splint in the treatment of mallet finger.
        J Hand Surg Br. 1986; 11: 261-262
        • Mason M.L.
        Mallet finger.
        Lancet. 1954; 266: 1220
        • Warren R.A.
        • Norris S.H.
        • Ferguson D.G.
        Mallet finger: a trial of two splints.
        J Hand Surg Br. 1988; 13: 151-153
        • Richards S.D.
        • Kumar G.
        • Booth S.
        • Naqui S.Z.
        • Murali S.R.
        A model for the conservative management of mallet finger.
        J Hand Surg Br. 2004; 29: 61-63
        • Minchin P.
        • Spirtos M.
        Investigation of the conservative management of mallet injury in Irish acute hospitals.
        Hand Ther. 2012; 17: 28-36
        • Hovgaard C.
        • Klareskov B.
        Alternative conservative treatment of mallet-finger injuries by elastic double-finger bandage.
        J Hand Surg. 1988; 13B: 154-155
        • Groth G.
        • Wilder D.M.
        • Young V.L.
        The impact of compliance on the rehabilitation of patients with mallet finger injuries.
        J Hand Ther. 1994; 7: 21-24
        • Pratt D.R.
        Internal splint for closed and open treatment of injuries of the extensor tendon at the distal joint of the finger.
        J Bone Joint Surg Am. 1952; 34a: 785-788
        • Devan D.
        A novel way of treating mallet finger injuries.
        J Hand Ther. 2014; 27 (quiz 329): 325-328
        • O’Brien L.
        The evidence on ways to improve patient’s adherence in hand therapy.
        J Hand Ther. 2012; 25: 247-250
        • Foucher G.
        • Binhamer P.
        • Cange S.
        • Lenoble E.
        Long-term results of splintage for mallet finger.
        Int Orthop. 1996; 20: 129-131
        • Katzman B.M.
        • Klein D.M.
        • Mesa J.
        • Geller J.
        • Caligiuri D.A.
        Immobilization of the mallet finger: effects on the extensor tendon.
        J Hand Surg Br. 1999; 24: 80-84