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Boutonniere Deformity Treatment & Management

  • Author: Wayne Reizner, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Jan 11, 2016
 

Acute Traumatic Boutonniere Deformity

In the setting of an acute injury to the central slip, conservative management should be employed in an attempt to permit tendon healing before the onset of a boutonnière (buttonhole) deformity (BD). Left untreated, an injury to the central slip can result in a BD within 2-3 weeks.

For an acute injury with a supple digit, management consists of either splinting or pinning of the proximal interphalangeal (PIP) joint in full extension for 4-6 weeks (see the image below). During this time, the distal interphalangeal (DIP) joint is not splinted; rather, this joint is taken through frequent flexion/extension exercises. Thereafter, PIP joint flexion exercises are introduced; however, PIP joint extension splinting is continued at night for an additional 4-8 weeks.[12, 13]

Bunnell safety-pin splint. Bunnell safety-pin splint.

In the case of a large avulsion of the dorsal lip of the middle phalanx, fixation with a Kirschner wire (K-wire) or screw fixation can be employed to reconstitute the extensor mechanism. If the fragment is small and nondisplaced, the injury can be managed nonoperatively with the splinting protocol as described above.

Open injuries should always be irrigated appropriately. The central slip should be repaired if it is completely lacerated. The proximal central slip tendon can be directly repaired to the residual central slip distally, or if there is insufficient tendon distally, the proximal end of the central slip can be anchored directly to the middle phalanx. In concert with nonoperative management, the PIP joint should be maintained in full extension to permit healing.

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Chronic Boutonniere Deformity

Classification

BDs can be categorized according to the Burton classification, as follows[14] :

  • Burton stage I - BD with a supple and passively correctable joint
  • Burton stage II - BD with a fixed contracture and contracted lateral bands; PIP joint spaces are maintained
  • Burton stage III - BD with a fixed deformity, contractures of lateral bands, volar plate and collateral ligaments; the PIP joint suffers from intra-articular fibrosis
  • Burton stage IV - BD with a fixed deformity, contractures of lateral bands, volar plate and collateral ligaments; the PIP joint suffers from intra-articular fibrosis and arthritis as evident on radiography

The Burton classification is based on the clinical examination and plain radiographs. Ultimately, surgical management is guided by the degree of deformity at the PIP joint, the suppleness or correctability of the joints, and the presence of arthritis at the PIP joint.[5, 15]

Management

For many patients, a BD does not impart excessive functional deficits; however, for those patients that suffer moderate-to-severe functional deficits, an operative approach may be indicated. In such instances, a detailed conversation with an orthopaedic hand surgeon should be pursued to explore the options and to arrive at appropriate expectations.

In the setting of a mild deformity, in which the PIP joint can be corrected passively, patients may still suffer from an extensor lag at the PIP joint and from hyperextension at the DIP joint. Because the functional limitation is secondary to the lack of PIP joint extension and DIP joint flexion, management is aimed at correcting these deformities.

To relieve the hyperextension at the DIP joint and to permit increased flexion, an extensor tenotomy overlying the middle phalanx can be performed. The extensor tenotomy is performed through a midaxial longitudinal incision overlying the dorsum of the middle phalanx, lengthening the extensor mechanism and returning a degree of flexion to the DIP joint. As the flexion deformity at the PIP joint is, by definition, passively correctable in a mild deformity, dynamic splinting is utilized to reduce the extension lag.[16, 17]

In patients with a moderate BD, the PIP joint flexion deformity may exceed 30°-40°. Nonetheless, if the PIP joint is passively correctable, the BDis amenable to soft-tissue reconstruction. Operative management entails reconstruction of the extensor mechanism through shortening of the central slip and reduction of the lateral bands dorsally.[18] It is vital to the functionality of the digit that PIP joint flexion be preserved; accordingly, such a reconstruction should not be performed in a patient with an incompetent flexor mechanism. This operation is often coupled with an extensor tenotomy to enable functional DIP flexion.

Severe BDs involve fixed contractures and may exhibit PIP joint arthrosis on radiographs. Fixed deformities are not amenable to the soft tissue reconstruction techniques described above. In an attempt to achieve extension at the PIP joint, dynamic splinting or serial casting may be employed to achieve passive extension. This may be coupled with soft-tissue releases, including releases of the accessory collateral ligaments.

In the setting of PIP arthrosis, management consists of fusion or arthroplasty. In PIP fusion, the joint is fused in relative flexion to permit grasping of objects. Splinting is utilized to allow union to occur over a period of 4-6 weeks. PIP joint arthroplasty, on the other hand, entails a more extensive approach, in that the surgeon must recreate and maintain functional motion at the PIP joint. Consequently, soft-tissue reconstruction is once again necessary and includes central slip shortening and reduction of the lateral bands dorsally.

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Postoperative Care

The full course of treatment of a BD should be discussed at the initiation of therapy. Patients will often wear a static splint maintaining full PIP extension after an operation to allow for healing. Thereafter, patients will proceed to intermittent splinting and undergo passive stretching exercises. Throughout the course of treatment, dedicated hand therapy is integral to the management and correction of a BD.

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Complications

Correction of a BD is not without complexity. While there is an attempt at improvement in function, patients may experience any of the following:

  • Continued debility
  • Incomplete correction of the deformity
  • Recurrence of the deformity
  • Loss of mobility—specifically, flexion at the PIP joint or extension at the DIP joint
  • Chronic pain
  • Infection at the site of open injury or the surgical site
  • Reoperation
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Contributor Information and Disclosures
Author

Wayne Reizner, MD Resident Physician, Department of Orthopedic Surgery, Mount Sinai St Luke’s-Roosevelt

Disclosure: Nothing to disclose.

Coauthor(s)

David A Forsh, MD Chief, Orthopedic Trauma Surgery, Assistant Professor, Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai

David A Forsh, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, AO North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

Randle L Likes, DO Consulting Staff, Department of Emergency Medicine, Gateway Medical Center

Randle L Likes, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Sean D Ghidella, MD Staff Physician, Puget Sound Orthopaedics

Sean D Ghidella is a member of the following medical societies: American Association for Hand Surgery

Disclosure: Nothing to disclose.

References
  1. Souter WA. The boutonniere deformity. J Bone Joint Surg Br. 1967. 49B:710-21.

  2. Coons MS, Green SM. Boutonniere deformity. Hand Clin. 1995 Aug. 11 (3):387-402. [Medline].

  3. Souter WA. The problem of boutonniere deformity. Clin Orthop. 1974 Oct. 0(104):116-33. [Medline].

  4. Kim JP, Go JH, Hwang CH, Shin WJ. Restoration of the central slip in congenital form of boutonniere deformity: case report. J Hand Surg Am. 2014 Oct. 39 (10):1978-81. [Medline].

  5. Feldon P, Terrono AL, Nalebuff EA, Millender LH. Rheumatoid arthritis and other connective tissue diseases. Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia: Elsevier; 2011. 2: 2052-6.

  6. Muir IFK, Barclay TL. Burns and Their Treatment. London: Lloyd-Luke; 1962. 109.

  7. Grishkevich VM. Surgical treatment of postburn boutonniere deformity. Plast Reconstr Surg. 1996 Jan. 97 (1):126-32. [Medline].

  8. Tsuge K. Congenital aplasia or hypoplasia of the finger extensors. Hand. 1975 Feb. 7 (1):15-21. [Medline].

  9. Carneiro RS. Congenital attenuation of the extensor tendon central slip. J Hand Surg Am. 1993 Nov. 18 (6):1004-7. [Medline].

  10. Elson RA. Rupture of the central slip of the extensor hood of the finger. A test for early diagnosis. J Bone Joint Surg Br. 1986 Mar. 68 (2):229-31. [Medline].

  11. Boyes JH. Bunnell's Surgery of the Hand. 5th ed. Philadelphia: JB Lippincott; 1971. 393.

  12. Griffin M, Hindocha S, Jordan D, Saleh M, Khan W. Management of extensor tendon injuries. Open Orthop J. 2012. 6:36-42. [Medline].

  13. Strickland JW. Flexor Tendon Injuries: I. Foundations of Treatment. J Am Acad Orthop Surg. 1995 Jan. 3 (1):44-54. [Medline].

  14. Burton RI. Extensor tendons--late reconstruction. Green DP, ed. Operative Hand Surgery. New York: Churchill Livingstone; 1988. 2073-116.

  15. Littler JW, Eaton RG. Redistribution of forces in the correction of Boutonniere deformity. J Bone Joint Surg Am. 1967 Oct. 49 (7):1267-74. [Medline].

  16. Meadows SE, Schneider LH, Sherwyn JH. Treatment of the chronic boutonniere deformity by extensor tenotomy. Hand Clin. 1995 Aug. 11 (3):441-7. [Medline].

  17. Stern PJ. Extensor tenotomy: a technique for correction of posttraumatic distal interphalangeal joint hyperextension deformity. J Hand Surg Am. 1989 May. 14 (3):546-9. [Medline].

  18. Curtis RM, Reid RL, Provost JM. A staged technique for the repair of the traumatic boutonniere deformity. J Hand Surg Am. 1983 Mar. 8 (2):167-71. [Medline].

 
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Lateral view of relevant finger anatomy.
Normal lateral band location, dorsal to axis of rotation of proximal interphalangeal joint.
After central slip disruption, lateral bands migrate volar to axis of rotation of proximal interphalangeal joint.
Boutonnière deformity. Image courtesy of David Bozentka, MD, University of Pennsylvania School of Medicine, published by Medscape (Late Reconstruction of Flexor and Extensor Tendon Injuries at http://www.medscape.com/viewarticle/717388).
Radiographic evidence of boutonnière deformities. Image courtesy of Radiopaedia.org; case by Dr Aditya Shetty (http://radiopaedia.org/cases/rheumatoid-arthritis-13).
Bunnell safety-pin splint.
Boutonnière deformity.
 
 
 
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