[Ortho] Нужен совет кистевых хирургов - что делать при отрыве сухожилий разгибателя ногтевой фаланги.

[SAGo]

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.

SAGo