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Re: Нужен совет кистевых хирургов - что делать при отрыве сухожилий разгибателя ногтевой фаланги.
послал SAGo 19 Июль 2016, 12:06
Я очень не люблю "железобетонные" стандарты в медицине. Но какой-то логично обоснованной линии надо все-таки придерживаться. Поэтому, например.

UpToDate
Extensor tendon injury of the distal interphalangeal joint (mallet finger)
Author: Rebecca Bassett, MD
Literature review current through: Jan 2016. | This topic last updated: Sep 11, 2015.

Acute mallet finger — The goal of mallet finger treatment is to maximize the function of the distal interphalangeal (DIP) joint while minimizing discomfort. The majority of mallet fingers are amenable to treatment with immobilization (ie, splinting), but some complex injuries warrant surgical referral. (See 'Indications for referral' above.)
The general consensus among experts is that uncomplicated mallet finger injuries without DIP joint subluxation are best treated with splinting. The central slip of the proximal interphalangeal (PIP) joint prevents excessive retraction of the damaged tendon, allowing close approximation and healing of the torn tendon sections to occur with splinting [12].
Most experts immobilize the DIP joint in full extension or slight hyperextension (5 to 15 degrees), while allowing full range of motion of the PIP joint. Clinical experience and the results of one cadaveric study that assessed the biomechanics of mallet finger injuries support this approach [13,14]. Primary care and emergency clinicians should not attempt to reduce any displaced fractures before splinting because any reduction is unlikely to be maintained without surgery; mallet fingers with associated fractures are referred.
An aluminum splint can be applied to either the palmar or dorsal surface of the middle and distal phalanx (picture 3). If possible, the splint should be bent slightly to stabilize the DIP joint in 5 to 10 degrees of hyperextension. Hyperextension may be limited initially by swelling or skin tightness. A stack splint may be used provided the splint is sufficiently tight to prevent any DIP flexion (picture 4). Custom-made perforated splints similar to stack splints can be made for fingers that are difficult to fit and they provide better aeration. An Abouna splint or metal ring splints are generally not used because of patient discomfort.
Care should be taken to avoid direct, sustained pressure from the splint on the area of the DIP joint. Excessive pressure or hyperextension can cause skin necrosis. The Kleinert modified dorsal splint attempts to avoid this complication by removing the middle third of the foam padding from the splint, thereby eliminating all direct pressure at the injury site (picture 5 and picture 6) [14].
In some instances, a swan neck deformity (indicating involvement of the central slip) accompanies a mallet finger injury. In such cases, both the DIP and the PIP joints should be immobilized in full extension [14]. Most cases heal well with splinting [10]. A swan neck deformity appears as a hyperextended PIP joint and a flexed DIP joint (figure 3).
A systematic review identified only four randomized or quasi-randomized placebo-controlled trials, involving a total of 278 patients that compared treatments for mallet finger [6]. One trial included in the review found no difference in outcomes or complications between fractures treated with splinting versus surgery using wire fixation.
Two systematic reviews found insufficient evidence to determine the best method for splinting a mallet finger, and the results of two subsequent randomized trials are consistent with this conclusion [6,15]. One review found fewer skin complications with custom orthosis versus prefabricated orthosis, but no differences in treatment success, failure, or extensor lag [15]. In a randomized trial involving 116 mallet fingers, patients with custom-made splints had fewer treatment failures compared to those with stack splints [16]. Improved outcomes in patients treated with custom splints were noted in one other randomized trial of 64 patients [17].
However, several trials have found that splint type does not affect outcome. A randomized trial involving 60 patients reported that aluminum splints fit better and caused fewer skin-related complications than stack splints, but both splints were equally effective for enabling tendon healing [18]. Another randomized trial of 77 patients reported no significant difference in extensor lag or complications based upon the type of splint selected [19]. We suggest selecting a splint based upon patient comfort in order to maximize compliance, provided the splint is sturdy and ensures adequate immobilization and proper positioning.
Follow-up — DIP joint extension splinting is performed for six to eight weeks. The DIP joint MUST be maintained in full extension throughout the entire period, including during sleep. Adherence to this instruction is essential. The most common reason for treatment failure is noncompliance. Whenever the splint is removed (eg, to clean the finger or change the splint), the patient must support the distal fingertip in full extension at all times. Should DIP joint extension be lost at any point during the initial treatment period, the treatment clock is reset and an additional six weeks of splinting must be performed. The patient should be seen every one to two weeks to check on compliance and complications.
After six to eight weeks of continuous extension splinting with the DIP joint maintained in full extension, the joint is reexamined and active extension assessed. If the patient is able to achieve full extension, an additional two to four weeks of nighttime splinting is performed.
Splinting should be maintained for ALL athletic events for another six weeks. If necessary, the foam padding of the aluminum splint may be removed and the aluminum secured directly to the dorsum of the finger to allow the returning athlete to fit the finger into a glove [12]. Active range-of-motion exercises are encouraged in these patients to minimize DIP stiffness.
If a significant extension lag (ie, volar angulation) persists following the initial six weeks of splinting, the splint is reapplied for up to six additional weeks [12]. As with the initial treatment period, the DIP joint MUST be strictly maintained in full extension throughout the second treatment period. The joint should be reexamined every two weeks during this second treatment period. Once an acceptable outcome is achieved, a night splint is used for two to four additional weeks.

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