Boutonnière Deformity Impormasyon In-depth

Ang iyong nararamdaman

Ang boutonnière deformity ay nagpapabago sa paraan ng pagbaluktot ng isa sa iyong mga daliri. Ang gitnang joint ng daliri ay nananatiling nakabaluktot pababa, at ang dulo ng joint ay nakaturo pataas sa halip na bumaluktot. Nangyayari ito kapag ang isang maliit at patag na tendon sa likod ng daliri (ang central slip) ay hindi na gumagana. Ang tendon na iyon ang karaniwang nagtutuwid sa gitnang joint. Kapag ito ay napunit, naunat, o napudpod, hindi na maitutuwid ng daliri ang bahaging iyon.

Maaaring maging masakit ang daliri, at maaari nitong gawing mas mahirap gamitin ang iyong kamay. Ang mga gawaing nangangailangan ng tuwid na daliri ay nagiging mahirap. Ang pagsusuot ng guwantes, pag-type, paghawak ng panulat, o pagpulot ng mga barya ay maaaring magmukhang kakatwa o hindi komportable. Anumang bagay na pumipindot sa nakabaluktot na joint, tulad ng paghawak sa manibela o pagbitbit ng shopping bag sa hawakan, ay maaaring magpalala sa sakit. Ang pagpapahinga ng kamay at pagpapanatiling hindi gumagalaw ng daliri ay karaniwang nakakapagpakalma nito.

Ang deformity na ito ay karaniwan sa mga taong may rheumatoid arthritis, kung saan ang patuloy na pamamaga sa loob ng gitnang joint (synovitis) ay dahan-dahang nagpupudpod sa tendon na iyon. Humigit-kumulang 36% ng mga taong may established rheumatoid arthritis ay may boutonnière deformity, at halos kalahati ang nagkakaroon ng boutonnière o swan-neck finger deformity. Maaari rin itong sumunod sa isang pinsala, tulad ng sugat o malakas na impact sa likod ng daliri na nakakasira sa central slip.

Ang pamamaga at sakit ay madalas na sumusunod sa isang pattern. Ang joint ay maaaring makaramdam ng paninigas at hapdi paggising, pagkatapos ay medyo luluwag habang nagsisimula kang gumalaw. Pagkatapos ng isang abalang araw ng paggamit ng kamay, ang daliri ay maaaring kumirot at makaramdam ng mas matinding pagbaluktot kaysa sa dati. Ang pagtibok-tibok (throbbing) ng joint sa gabi ay karaniwan din kapag ang daliri ay labis na nagamit.

Isang bagay na mahalagang malaman: mahalaga ang maagang pagtuklas nito. Kung ang pinsala sa central slip ay magagamot agad pagkatapos itong mangyari, ang deformity ay madalas na maiiwasang mabuo.

Ano ang aktwal na nangyayari

Isipin ang tendon sa likod ng iyong daliri bilang isang lubid na tumatakbo sa itaas at nahahati sa mga hibla malapit sa gitnang joint. Ang isang hibla, ang central slip, ay nakakabit sa gitnang buto at nagtutuwid sa joint na iyon. Dalawa pang hibla ang tumatakbo sa magkabilang panig nito. Karaniwan, ang tatlong ito ay nagtutulungan, na pinapanatili sa pwesto sa ibabaw ng joint ng mga manipis na sheet ng tissue, gaya ng mga guy rope na humahawak sa poste ng tent upang manatiling nakatayo.

Kapag ang daliri ay napinsala, o kapag ang rheumatoid arthritis ay nagpapagasgas sa tendon palayo sa loob ng joint, ang central slip ay maaaring mapunit o mabanat. Kapag bumitaw na ito, ang dalawang side strand ay dumudulas sa ilalim ng joint sa halip na tumakbo sa itaas. Mula roon, hinihila nila ang gitnang joint pababa sa isang nakabaluktot na posisyon sa halip na ituwid ito. Iyan ang dahilan kung bakit ang iyong daliri ay nananatiling nakabaluktot sa gitnang joint at nakaturo pataas sa dulo.

Kailangan ng higit sa isang napinsalang bahagi upang mangyari ito. Ang central slip, ang mga sheet ng tissue na humahawak sa mga hibla sa pwesto, at ang ilang mga fiber sa paligid nito ay kailangang maapektuhan bago aktwal na dumulas ang mga hibla palabas ng posisyon. Iyan din ang dahilan kung bakit ang isang daliri ay maaaring maramdamang tila pumipitik o sumasabit sa gitnang joint sa simula, bago pa man mabuo ang buong deformity.

Isang bagay pa na mahalagang malaman. Kapag ang deformity ay matagal nang naroon, ang joint mismo ay tumitigas at nag-aadjust sa nakabaluktot nitong posisyon. Kahit may gamutan, maaaring manatili ang ilang degrees ng kawalan ng pagtuwid sa gitnang joint. Ito ang dahilan kung bakit napakahalaga ng maagang gamutan, gaya ng ipinaliwanag sa seksyon sa itaas.

Ano ang maaari naming gawin tungkol dito

Si Dr Kieran Hirpara, isang upper-limb surgeon sa Mater Private Hospital Rockhampton, ay nagsisimula sa mga opsyon na hindi gaanong invasive na angkop sa iyong kondisyon. Ang mga pasyente ay karaniwang nirerefer sa aming klinika ng kanilang GP; kung iminungkahi ng isang physiotherapist na magpatingin sa amin, kakailanganin mo pa rin ng referral mula sa iyong GP upang maging eligible para sa Medicare rebate. Sa iyong unang pagbisita, kumukuha kami ng history, sinusuri ang iyong daliri, at nag-aayos ng imaging kung saan lamang ito makakapagpabago ng plano. Ang isang maingat na pagsusuri ang nagtuturo sa amin sa mga tamang test at tamang gamutan.

Para sa isang deformity na matagal na, karaniwan kaming nagsisimula sa splinting. Kapag sapat na ang tagal na napanatiling tuwid ang daliri, magsusuot ka ng splint na humahawak sa daliri sa isang posisyon na nagpapahintulot sa iyong patuloy na paggamit ng iyong kamay. Isusuot mo ito sa loob ng 3 buwan. Gumagana ito kapag naibalik ng paunang splinting ang middle joint sa extension na mas mababa sa -20°, ibig sabihin ay kaya nitong tumuwid lampas sa point na 20 degrees bago ang pagiging fully straight, at aktibo mong ginagamit ang splint sa buong panahon. Ang pagsisimula ng gamutan sa loob ng 6 na linggo mula sa pinsala ay nagbibigay ng malaking pagkakaiba sa dami ng paggalaw na mababawi mo. Para sa isang bagong central slip injury, pinapanatili namin ang middle joint ng daliri sa full extension (ganap na tuwid) sa loob ng apat na linggo, habang patuloy na gumagalaw ang end joint, pagkatapos ay gumagamit ng spring-loaded splint sa loob ng dalawa pang linggo. Sa kalakhan ng panahong iyon, maaari mo pa ring gamitin ang iyong kamay para sa mga magagaan na gawain.

Kapag ang splinting ay hindi nagbigay sa iyo ng sapat na pagtuwid, ang operasyon ang susunod na hakbang. Isinasaalang-alang namin ito kapag ang tendon ay napinsala na nang higit pa sa kayang ayusin ng splint, o kapag ang deformity ay naging fixed na sa posisyon nito. Binubuo muli ng operasyon ang tendon mechanism sa likod ng iyong daliri upang muli nitong mapatuwid ang middle joint. Kung ang mga side strand ng tendon ay pudpod o pinsala, maaari namin itong muling buuin gamit ang isang strip ng tendon mula sa iyong sariling wrist. Ang mga detalye ng bawat operasyon ay may sariling pahina, at pag-uusapan namin kung alin ang angkop para sa iyong daliri bago gumawa ng anumang desisyon.

Ano ang dapat asahan

Ang takbo ng mga bagay ay nakadepende nang malaki sa kung gaano kabilis nagamot ang daliri. Kung ang isang bagong central slip injury ay nalagyan agad ng splint, madalas na maiiwasan ang pagbuo ng deformity. Kung hahayaan lamang ito, ang gitnang joint ay karaniwang nananatiling nakabaluktot at maaaring maging fixed sa posisyong iyon sa paglipas ng panahon. Kapag ang deformity ay matagal na, kahit ang mahusay na paggamot ay maaaring mag-iwan sa daliri na kulang ng ilang digri bago ito maging ganap na tuwid.

Para sa deformity na nanatili na, ang mga unang hakbang ay mga cast upang ituwid ang gitnang joint, na susundan ng 3 buwan na pagsuot ng splint habang patuloy mong ginagamit ang iyong kamay. Gumagana ito kapag ang mga cast ay kayang dalhin ang joint sa mas mababa sa -20° ng extension, ibig sabihin ay naitutuwid ito lampas sa punto na 20 digri bago ang ganap na pagtuwid. Kailangan mong gamitin nang aktibo ang iyong kamay sa loob ng splint na iyon sa buong 3 buwan upang maibalik ang iyong bending movement. Ito ay isang mabagal na proseso, at may hinihingi itong pagsisikap mula sa iyo: ang splint ay makakatulong lamang kung aktwal mong igagalaw ang daliri habang suot ito.

Kapag nagawa na ng splinting ang lahat ng kaya nito, ang operasyon ang susunod na hakbang. Kung saan ang mga side strand ng tendon ay pudpod o damaged, isang strip ng tendon mula sa iyong sariling pulso ang maaaring gamitin upang muling buuin ang mga ito. Sa mga taong sumailalim sa operasyong iyon para sa isang long-standing deformity, ang mga resulta ay mabuti o mahusay sa 16 sa 18 pasyente. Ang isa pang opsyon para sa long-standing deformity ay ang pagputol ng tendon sa dulo ng joint, na kapansin-pansing nagpababa ng disability at nagbalik ng pagbaluktot sa joint na iyon sa mga taong sumailalim dito.

Ilang tapat na babala. Sa mga huling yugto ng deformity na ito, ang mga soft-tissue operation lamang ay maaaring hindi mapanatili ang koreksyon nang permanente. At kung ikaw ay may rheumatoid arthritis, ang mga deformity sa daliri ay maaaring patuloy na mabuo habang lumalala ang underlying condition, kaya ang iyong treatment plan ay titimbangin kung gaano ka-fixed ang joint, kung paano ito gumagalaw, at ang estado ng joint surface. Hindi ibig sabihin nito na hindi makakatulong ang operasyon. Ibig sabihin nito ay ang layunin ay isang daliri na mas gumagana, hindi isang pangako ng isang perpektong tuwid na daliri.

Kailan dapat magpatingin

Magpatingin sa iyong GP kung ang isang daliri ay nagsimulang bumaluktot sa gitnang joint at hindi na maituwid, lalo na kung mayroon kang rheumatoid arthritis. Humingi ng pagsusuri ng isang espesyalista kung ang gitnang joint ay masakit, kumakagat o pumipitik, o kung ang daliri ay nagiging mas mahirap gamitin sa mga pang-araw-araw na gawain. Ang mga pagbabagong ito ay maaaring dahan-dahang lumitaw, kaya madali itong mapagkamalang dulot lamang ng sobrang paggamit. Mahalaga ang timing: ang pagsisimula ng gamutan sa loob ng 6 na linggo matapos ang pinsala ay nagbibigay ng malaking pagkakaiba sa dami ng paggalaw na mababawi, at kapag ang isang deformity ay matagal na, nagiging mas mahirap na itong itama. Kung mapansin mong ang isang daliri ay bumabaluktot pababa sa gitnang joint habang ang dulo ng joint ay nakaturo pataas, huwag hintayin na kusa itong gumaling.

Higit pang detalye

Advanced reading: the deeper science (optional)

Ang seksyong ito ay higit pa sa kailangan mo para sa iyong sariling mga desisyon sa paggamot. Ang boutonnière deformity ay karapat-dapat sa karagdagang pagbabasa dahil ang instinktibong paggamot para sa isang masakit, namamagang, at nakabaluktot na daliri—ang pagpapahinga sa buong daliri at pagpapanatiling hindi gumagalaw ang lahat nito—ay hindi ang sinusuportahan ng ebidensya: ang middle joint ay pinapanatiling tuwid habang patuloy na gumagalaw ang end joint.

Maagang mobilisasyon, hindi pinahabang immobilisasyon

Ang isang sistematikong pagsusuri ng mga gamot para sa central slip injury ay nakatagpo na limitado ang basehan ng ebidensya, kung saan ang mga papel ng iba't ibang estratehiya para sa parehong open at closed injuries ay hindi gaanong suportado [1]. Sa loob ng limitasyong iyon, ang ebidensya mula sa mga indibidwal na pag-aaral ay tentatibong sumusuporta sa maagang mobilisasyon at hindi sumusuporta sa pinahabang immobilisasyon [1].

Karapat-dapat itong sabihin nang malinaw dahil ito ay salungat sa reflex. Ang pagkakaiba ay sa pagitan ng pagprotekta sa naghihilom na central slip, na nangangailangan na ang middle joint ay panatilihing diretso, at ang pag-immobilise sa buong daliri, na nagpapahintulot sa fingertip joint na tumigas sa extension at sa buong digit na maging rigid. Ang splint ay nilalayong hawakan ang isang joint habang ang iba ay patuloy na gumagalaw.

Bakit lumalala ang deformity sa halip na manatili lang ito

Ang Boutonnière ay isang progressive deformity, na hindi karaniwan at mahalagang maunawaan. Ang central slip ay nakakabit sa base ng middle bone at nagtutuwid sa middle joint. Kapag ito ay pumalya, ang joint na iyon ay bumabagsak sa flexion, at ang dalawang lateral bands, na karaniwang tumatakbo sa itaas ng axis ng joint, ay nadudulas pababa nito.

Kapag sila ay nasa ibaba na ng axis, ang mga tendon na dati ay tumutulong sa pagtutuwid ng middle joint ay nagsisimulang ibaluktot ito, habang hinihila ang fingertip patungo sa hyperextension. Dahil dito, ang deformity ay nagiging self-reinforcing: bawat pagtatangka na ituwid ang daliri ay naghihigpit sa mga istrukturang kasalukuyang humahawak dito nang nakabaluktot. Ito ang dahilan kung bakit ang isang pinsala na mukhang maliit ay maaaring magdulot ng fixed deformity pagkalipas ng ilang linggo, at kung bakit maikli lamang ang window para sa simpleng splinting.

Ang deformity na hindi boutonnière

Ang isang daliri ay maaaring magkaroon ng parehong postura kahit walang injury sa central slip, at ang mga gamutan ay lubos na magkaiba. Ang mga deformity na boutonnière at pseudoboutonnière ay magkaiba sa pathoanatomy, diagnosis at management [2], kung saan ang pseudo variety ay nagmumula sa isang volar plate injury sa middle joint, kung saan ang fingertip joint ay nananatiling may normal na passive flexion sa halip na mahila patungo sa hyperextension.

Ang pagtukoy sa mga ito sa bedside ay nakadepende sa fingertip. Sa isang tunay na boutonnière, ang tip ay nananatiling hyperextended at lumalaban kapag ibinabaluktot, lalo na kapag ang middle joint ay tuwid; sa isang pseudoboutonnière, ito ay malayang nag-f-flex. Ang pag-splint sa isang pseudoboutonnière na tila ito ay tunay na boutonnière ay tumutugon sa maling joint.

Bahagi ito ng pamilya ng mga pinsala na tinutukoy base sa kung saan nabigo ang tendon

Ang Boutonnière ay kasama ng mallet finger at sagittal band injury bilang isa sa tatlong closed extensor mechanism injuries, na kinategorya ayon sa zone kung saan nabigo ang mekanismo [3]. Ang tatlo ay maaaring magpakita bilang isang namamagang daliri na nakaposisyon nang abnormal sa loob ng ilang araw matapos ang pinsala, at ang bawat isa ay nangangailangan ng magkakaibang posisyon ng splint, na siyang praktikal na dahilan kung bakit mahalagang makamit ang isang tiyak na diagnosis bago magsimula sa ilang linggong pag-splint.

Mga Sanggunian

[1] Geoghegan L, Wormald JCR, Adami RZ, Rodrigues JN. Central slip extensor tendon injuries: a systematic review of treatments. J Hand Surg Eur Vol. 2019;44(8):825-32. https://doi.org/10.1177/1753193419845311

[2] Hanson ZC, Thompson RG, Andrews JR, Lourie GM. Boutonniere versus pseudoboutonniere deformities: pathoanatomy, diagnosis, and treatment. J Hand Surg Am. 2023;48(5):489-97. https://doi.org/10.1016/j.jhsa.2022.10.019

[3] Lin JD, Strauch RJ. Closed soft tissue extensor mechanism injuries (mallet, boutonniere, and sagittal band). J Hand Surg Am. 2014;39(5):1005-11. https://doi.org/10.1016/j.jhsa.2013.11.018

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [1].
An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities [2].
Early treatment of central slip injuries can prevent the deformity [3].
The natural history of the boutonnière deformity in rheumatoid arthritis is outlined in the literature [5].
Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension [6].
For chronic boutonniere deformity, the patient must actively use the hand in a relative motion flexion orthosis for 3 months to recover flexion [6].
Serial casting for adequate extension followed by 3 months of relative motion flexion orthotic use should be attempted prior to surgical intervention for chronic boutonniere deformity [4].
Extensor tenotomy to correct a boutonnière deformity of long standing markedly lessened disability with restoration of flexion of the distal joint [10].
Transection of the terminal extensor tendon is a useful procedure for salvage of the boutonniere deformity [13].
The Y-shaped tendon graft can be a useful procedure for the correction of chronic boutonniere deformity [7].
In a patient series, the Y-shaped tendon graft provided good or excellent results in 16 of 18 patients for chronic boutonniere deformity [7].
The cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option with satisfactory results for chronic boutonniere deformity when the lateral bands are deficient or damaged [9].
Congenital boutonniere deformity is understood as various embryonic developmental failures [8].
Central slip reconstruction is a reliable surgical option for the congenital form of boutonniere deformity [8].

Anatomy & Pathophysiology

Extensor Mechanism Anatomy

The extensor mechanism of the finger at the level of the proximal interphalangeal (PIP) joint consists of both intrinsic and extrinsic contributions [19].
The extensor tendon entering the digit is the continuation of the extensor digitorum communis (EDC), with contributions from the extensor indicis proprius in the index finger and the extensor digiti quinti in the small finger [19].
In 30% of cases, the EDC has a separate insertion into the base of the proximal phalanx, but extension of the metacarpophalangeal (MP) joint most often occurs through the pull of the sagittal bands [19].
The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the MP joint [25].
At the level of the middle of the proximal phalanx, transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [25].
Oblique fibers (spiral fibers) from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx, extending the middle phalanx at the PIP joint [25].
The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [25].
The two conjoined lateral bands unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx to extend it [25].
The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [25].
The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [25].

Pathomechanics and Injury

A boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the PIP joint [15].
Damage to the central slip alone does not cause a boutonniere deformity [15].
A boutonniere deformity occurs only when the central slip, triangular ligament, and transverse and oblique fibers of the interosseous hood are all damaged [15].
Detachment of the central slip from the middle phalanx produces a decrease in extension of the PIP joint [15].
When the transverse and oblique fibers of the interosseous hood are divided in addition to the central slip, extension at the PIP joint is further decreased [15].
Extension of the PIP joint decreases as structures are progressively damaged [40].
Injury to the extensor mechanism, specifically the central slip, can lead to snapping or catching at the PIP joint [39].
In irreducible volar dislocations of the PIP joint caused by interposition of the intact central slip, the extensor mechanism is displaced rather than disrupted [47].
Long-standing complex pathophysiological changes in boutonniere deformity make full correction impossible, resulting in an inevitable few degrees of PIP joint extension deficit [46].

Classification

The boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the PIP joint [15].
Combined injury of the central slip, triangular ligament, and transverse and oblique fibers of the interosseous hood causes a boutonniere deformity [15].
Anterior dislocation of the proximal interphalangeal joint is associated with ruptures of the central slip of the extensor mechanism [18].
Anterior dislocation of the proximal interphalangeal joint results in boutonnière deformity unless repaired [18].
The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13% [11].

Clinical Presentation

A swan-neck or boutonniere deformity occurs in approximately half of patients with rheumatoid arthritis [16].
The incidence of uncorrectable swan-neck and boutonniere deformities is estimated to be between 8% and 16% during the first 2 years after the onset of systemic disease [16].
The prevalence of finger deformities in patients with established rheumatoid arthritis is approximately 36% for boutonniere deformities [16].
The cause of boutonniere deformity in rheumatoid arthritis is chronic synovitis of the proximal interphalangeal joint [16].
Boutonniere deformities can be painful and can impair finger and hand function significantly [16].
A boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the proximal interphalangeal joint [15].
Detachment of the central slip from the middle phalanx produces a decrease in extension of the proximal interphalangeal joint [15].
Division of the central slip leads to loss of extension at the proximal interphalangeal joint [15].

Investigations

A careful physical examination is essential to direct care and future testing if indicated [22].
Diagnostic tests such as imaging and serum laboratory studies are useful in the determination of pathology but can be expensive, time consuming, and often nonspecific [22].
The extensor mechanism of the finger at the level of the PIP joint consists of both intrinsic and extrinsic contributions [19].
The extensor tendon that enters the digit is the continuation of the extensor digitorum communis (EDC) and in the index and small fingers the extensor indicis proprius and extensor digiti quinti, respectively [19].
Thirty percent of the time the EDC has a separate insertion into the base of the proximal phalanx [19].
Extension of the metacarpophalangeal (MP) joint most of the time occurs through the pull of the sagittal bands [19].
A finite element model was developed and validated that successfully replicated the behavior of the digit under specific scenarios, including the extension of the DIP joint during Elson's test observed in cadaveric studies [12].
In a cadaver model, detachment of the central slip from the middle phalanx produced a decrease in extension of the PIP joint [15].
In a cadaver model, when the transverse and oblique fibers of the interosseous hood were also divided, extension at the PIP joint was further decreased [15].
In a cadaver model, a boutonniere deformity occurred only when the central slip, triangular ligament, and transverse and oblique fibers of the interosseous hood were all damaged [15].

Non-Operative

Chronic boutonniere deformity should be treated with serial casting for adequate extension followed by 3 months of relative motion flexion (RMF) orthotic use prior to surgical intervention [4].
Chronic boutonniere deformity responds to relative motion flexion splinting if serial casting places the proximal interphalangeal joint in less than -20° extension and the patient actively uses a relative motion flexion orthosis for 3 months [6].
The use of relative motion flexion orthoses (RMFO) is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity [36].
Improvement in digit range of motion is associated with the initiation of treatment within 6 weeks [21].
Improvement in digit range of motion is not associated with any particular type or length of conservative treatment [21].
Conservative treatment for central slip injuries involves immobilization of the proximal interphalangeal joint, distal interphalangeal joint, and metacarpophalangeal joint in full extension for four weeks followed by a Capener spring splint for two further weeks [45].
In a review of 115 central slip injuries, 24 uncomplicated closed or compound injuries treated conservatively resulted in 17 patients (71%) achieving an outcome of less than a 20° extension deficit at the PIPJ and more than 80% return of PIPJ flexion [45].
Patients treated within six weeks of injury had better outcomes in conservative management of central slip injuries [45].

Operative

A simple method of repair is described for the correction of the boutonnière deformity in rheumatoid arthritis [5].
The Y-shaped tendon graft is a useful procedure for the correction of chronic boutonniere deformity [7].
The cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option for chronic boutonniere deformity when the lateral bands are deficient or damaged [9].
The cross-lateral band reconstruction technique using palmaris longus autograft yields satisfactory results in chronic boutonniere deformity [9].

Complications

The prevalence of finger deformities in patients with established rheumatoid arthritis is approximately 14% for swan-neck deformities [16].
Swan-neck deformity may be caused by synovitis of the metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joints [16].
In the later stages of both swan-neck and boutonniere deformities, soft-tissue procedures alone may not result in lasting operative correction [16].

Recovery

Chronic boutonniere deformity should be treated with serial casting for adequate extension followed by 3 months of relative motion flexion orthotic use prior to surgical intervention [4].
Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion [6].
The Y-shaped tendon graft provided good or excellent results in 16 of 18 patients for the correction of chronic boutonniere deformity [7].
The incidence of uncorrectable swan-neck and boutonniere deformities is estimated to be between 8% and 16% during the first 2 years after the onset of systemic disease in rheumatoid arthritis [16].
The prevalence of finger deformities in patients with established rheumatoid arthritis is approximately 14% for swan-neck deformities and 36% for boutonniere deformities [16].
Treatment decisions for boutonniere deformity in rheumatoid arthritis are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface [20].

Key Evidence

[L5] Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management. [1] (10.1016/j.jhsa.2022.10.019)
[L5] An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities. [2] (10.5435/jaaos-d-14-00272)
[L5] The paper outlines the anatomy, pathoanatomy, and treatment concepts for boutonniere deformity, emphasizing that early treatment of central slip injuries can prevent the deformity. [3] (10.1016/s0749-0712(21)00060-3)
[L4] Similar results occurred for chronic boutonniere deformity using serial casting for adequate extension followed by 3 months of RMF orthotic use, which should be attempted prior to surgical intervention. [4] (10.1016/j.jht.2023.02.005)
[L4] The natural history of the boutonnière deformity in rheumatoid arthritis is outlined, and a simple method of repair is described. [5] (10.2106/00004623-196951070-00009)
[L4] Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension, and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion. [6] (10.1097/sap.0000000000002307)
[L4] The Y-shaped tendon graft can be a useful procedure for the correction of chronic boutonniere deformity; in our patient series, this provided good or excellent results in 16 of 18 patients. [7] (10.1016/j.jhsa.2021.01.003)
[Case_report] The case extends understanding of congenital boutonniere deformity as various embryonic developmental failures and suggests a reliable surgical option involving central slip reconstruction. [8] (10.1016/j.jhsa.2014.05.030)
[L4] In chronic boutonniere deformity, when the lateral bands are deficient or damaged, the cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option with satisfactory results. [9] (10.1016/j.jhsa.2017.04.010)
[L3] The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13%. [11] (10.1177/1753193417704610)
[L5] The study developed and validated a finite element model that successfully replicated the behavior of the digit under specific scenarios, including the extension of the DIP joint during Elson's test observed in cadaveric studies. [12] (10.1186/s13018-025-06329-3)
[L4] Transection of the terminal extensor tendon is a useful procedure for salvage of the boutonniere deformity. [13] (10.1016/s0749-0712(21)00065-2)
[L5] [15] (10.1016/j.jhsa.2017.07.011)
[L5] [16] (10.5435/00124635-199903000-00002)
[Paper] [19] (10.1016/j.hcl.2012.05.044)
[L5] Treatment decisions are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface. [20] (10.1016/j.jhsa.2011.05.029)
[L3] Improvement in digit ROM was associated with initiation of treatment within 6 weeks, but not with any particular type or length of conservative treatment. [21] (10.1016/j.jht.2025.02.013)
[L4] The use of RMFO is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity. [36] (10.1016/j.jhsa.2022.08.007)
[Case_report] Hand surgeons should be aware that injury to the extensor mechanism and specifically the central slip can lead to snapping or catching at the PIP joint in the finger. [39] (10.1177/15589447221081876)
[Paper] Extension of the PIP joint decreases as these structures are progressively damaged. [40] (10.1016/s0363-5023(12)60014-8)
[L4] [45] (10.1177/1758998318822663)
[L4] Due to long-standing complex pathophysiological changes, full correction may not be possible, and a few degrees of PIP joint extension deficit is inevitable. [46] (10.1016/j.otsr.2021.102971)
[L4] The prognosis is far better after irreducible than after reducible volar dislocations because the extensor mechanism is displaced, not disrupted. [47] (10.2106/00004623-197860010-00023)

References

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[11] Thumb boutonnière deformity without rheumatoid arthritis or trauma. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417704610

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[20] Treatment of Boutonniere Finger Deformity in Rheumatoid Arthritis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.029

[21] Nonoperative treatment of the Boutonniere deformity: Is there a difference in outcomes?. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2025.02.013

[22] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[25] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[36] The Use of Relative Motion Flexion Orthoses for Chronic Boutonniere Deformity. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2022.08.007

[39] Longitudinal Tear of the Central Slip Causing Painful and Unusual Snapping of the Finger: A Case Report. HAND. 2022. DOI: 10.1177/15589447221081876

[40] Biomechanics of the Acute Boutonniere Deformity. The Journal of Hand Surgery. 2012. DOI: 10.1016/s0363-5023(12)60014-8

[45] Therapeutic management of closed central slip injuries: Outcome of a service evaluation. Hand Therapy. 2019. DOI: 10.1177/1758998318822663

[46] RETRACTED: Flexor Digitorum Superficialis tendon transfer for a long-standing boutonniere deformity finger- a retrospective study of 11 cases. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102971

[47] Irreducible volar dislocation of the proximal interphalangeal joint of a finger caused by interposition of the intact central slip. The Journal of Bone & Joint Surgery. 1978. DOI: 10.2106/00004623-197860010-00023