பூட்டோனியர் கோளாறு

Overview

• Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [2].
• An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonniere and swan neck deformities [4].
• The natural history of the boutonnière deformity in rheumatoid arthritis is outlined, and a simple method of repair is described [3].
• The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13% [5].
• One to two grades of ROM improvement can be achieved with nonoperative treatment, although deformity can persist even after dedicated conservative management [8].
• 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 [1].
• Long-term results following soft tissue reconstruction for boutonniere deformity in rheumatoid arthritis are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure [9].
• A successful operative result for swan-neck and boutonniere deformities in the rheumatoid hand depends on complete preoperative examination, correct staging of the deformity, and proper timing of treatment [10].
• The Y-shaped tendon graft can be a useful procedure for the correction of chronic boutonniere deformity, providing good or excellent results in 16 of 18 patients in one series [6].
• Detachment of up to two-thirds of the phalangeal length was effective in reducing extensor lag of the DIP joint and did not cause any boutonniere deformity in a cadaveric model of fractional Fowler tenotomy for chronic mallet finger [7].

Anatomy & Pathophysiology

• Boutonnière deformity can persist even after dedicated conservative management [8].
• One to two grades of range of motion improvement can be achieved with nonoperative treatment of Boutonnière deformity [8].
• Accurate diagnosis and treatment of finger metacarpophalangeal joint injuries begins with an understanding of all potential diagnoses [15].
• Hand surgery and hand therapy practice interventions, including use of relative motion flexion orthoses for management of non-surgical and surgical extensor mechanism injuries, may benefit from an in-depth look at extensor mechanism zone III and IV anatomy and biomechanics [19].
• The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages [21].
• Reconstruction of the extensor central slip using a distally based flexor digitorum superficialis slip provides a robust repair that anatomically mimics the extensor central slip while maintaining the function of the donor FDS tendon [24].
• The main goals of any treatment of a proximal interphalangeal joint complication are maintaining concentric reduction of the joint, restoring joint stability, and facilitating early range-of-motion exercises [33].

Classification

• Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [2].
• The natural history of the boutonnière deformity in rheumatoid arthritis is outlined [3].
• The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13% [5].
• A modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis could detect advanced deformity earlier and was more strongly correlated with hand function [17].

Clinical Presentation

• Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [2].
• An understanding of the clinical presentation is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities [4].
• Accurate diagnosis of finger metacarpophalangeal joint injuries begins with an understanding of all potential diagnoses [15].
• The natural history of the boutonnière deformity in rheumatoid arthritis is outlined in historical literature [3].
• The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13% [5].
• The swan neck deformity can progress significantly with time due to increasing distal interphalangeal joint flexion contracture [14].

Investigations

• Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [2].
• An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities [4].
• Accurate diagnosis and treatment of finger metacarpophalangeal joint injuries begins with an understanding of all potential diagnoses [15].
• It is necessary to determine the true etiology before surgical intervention [12].
• A successful operative result depends on complete preoperative examination, correct staging of the deformity, and proper timing of treatment [10].
• Cortical breaks were commonly visualized in MCP and PIP joints with HR-pQCT and microCT [37].

Treatment

• Serial casting for adequate extension followed by 3 months of relative motion flexion (RMF) orthotic use should be attempted prior to surgical intervention for chronic boutonniere deformity [1].
• Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [2].
• A simple method of repair is described for the boutonnière deformity in rheumatoid arthritis [3].
• Understanding the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities [4].
• The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13% [5].
• The Y-shaped tendon graft is a useful procedure for the correction of chronic boutonniere deformity, providing good or excellent results in 16 of 18 patients in a reported series [6].
• Detachment of up to two-thirds of the phalangeal length is effective in reducing extensor lag of the DIP joint and does not cause any boutonniere deformity in a cadaveric model [7].
• One to two grades of ROM improvement can be achieved with nonoperative treatment, although deformity can persist even after dedicated conservative management [8].
• Long-term results following soft tissue reconstruction for boutonniere deformity in rheumatoid arthritis are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure [9].
• A successful operative result for swan-neck and boutonniere deformities in the rheumatoid hand depends on complete preoperative examination, correct staging of the deformity, and proper timing of treatment [10].
• Metacarpophalangeal joint arthroplasty improves function and deformity and achieves nearly uniform patient satisfaction in rheumatoid arthritis [11].
• One technique does not treat all finger deformities uniformly, highlighting the need to determine the true etiology before surgical intervention [12].
• 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 [13].

Complications

• Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [2].
• The prevalence of boutonniere deformity without rheumatoid arthritis or trauma is approximately 13% [5].
• Detachment of up to two-thirds of the phalangeal length was effective in reducing extensor lag of the DIP joint and did not cause any boutonniere deformity in a cadaveric model [7].
• Long-term results following soft tissue reconstruction for boutonniere finger deformity in rheumatoid arthritis are unreliable [9].
• Recurrent or persistent deformity is best treated with a salvage procedure [9].
• A successful operative result depends on complete preoperative examination, correct staging of the deformity, and proper timing of treatment [10].
• One technique does not treat all deformities uniformly, highlighting the need to determine the true etiology before surgical intervention [12].
• Swan neck deformity can progress significantly with time due to increasing DIPJ flexion contracture [14].

Recovery

• Serial casting for adequate extension followed by 3 months of relative motion flexion (RMF) orthotic use yields similar results for chronic boutonniere deformity and should be attempted prior to surgical intervention [1].
• One to two grades of range of motion (ROM) improvement can be achieved with nonoperative treatment, although deformity can persist even after dedicated conservative management [8].
• The Y-shaped tendon graft is a useful procedure for the correction of chronic boutonniere deformity, providing good or excellent results in 16 of 18 patients in a reported series [6].
• The use of relative motion flexion orthoses (RMFO) is effective in increasing active distal interphalangeal joint flexion and improving proximal interphalangeal (PIP) extension in patients with Burton stage 1 chronic boutonniere deformity [13].
• Long-term results following soft tissue reconstruction for boutonniere deformity in rheumatoid arthritis are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure [9].
• A successful operative result for boutonniere deformity depends on complete preoperative examination, correct staging of the deformity, and proper timing of treatment [10].

Key Evidence

• [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. [1] (10.1016/j.jht.2023.02.005)
• [L5] Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management. [2] (10.1016/j.jhsa.2022.10.019)
• [L4] The natural history of the boutonnière deformity in rheumatoid arthritis is outlined, and a simple method of repair is described. [3] (10.2106/00004623-196951070-00009)
• [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. [4] (10.5435/jaaos-d-14-00272)
• [L3] The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13%. [5] (10.1177/1753193417704610)
• [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. [6] (10.1016/j.jhsa.2021.01.003)
• [L5] Detachment of up to two-thirds of the phalangeal length was effective in reducing extensor lag of the DIP joint and did not cause any boutonniere deformity in this cadaveric model. [7] (10.1016/j.jhsa.2012.07.039)
• [L3] One to two grades of ROM improvement can be achieved, although deformity can persist even after dedicated conservative management. [8] (10.1016/j.jht.2025.02.013)
• [L5] Long-term results following soft tissue reconstruction are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure. [9] (10.1016/j.jhsa.2011.05.029)
• [L5] A successful operative result depends on complete preoperative examination, correct staging of the deformity, and proper timing of treatment. [10] (10.5435/00124635-199903000-00002)
• [L5] Follow-up studies show that this surgery improves function and deformity and achieves nearly uniform patient satisfaction. [11] (10.5435/00124635-200305000-00005)
• [L5] It emphasizes that one technique does not treat all deformities uniformly and highlights the need to determine the true etiology before surgical intervention. [12] (10.1016/j.jhsa.2022.07.008)
• [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. [13] (10.1016/j.jhsa.2022.08.007)
• [L5] The swan neck deformity in this individual progressed significantly with time because of increasing DIPJ flexion contracture. [14] (10.1016/j.jht.2009.11.005)
• [L5] Accurate diagnosis and treatment of finger metacarpophalangeal joint injuries in athletes begins with an understanding of all potential diagnoses, allowing for safe and early return to play. [15] (10.5435/jaaos-d-21-01031)
• [L3] The modified classification could detect advanced deformity earlier and was more strongly correlated with hand function. [17] (10.1177/1753193419886719)
• [L5] Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics. [19] (10.1016/j.jht.2023.01.002)
• [L4] The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages. [21] (10.2106/00004623-195739030-00006)
• [L4] The modified technique provides a robust repair that anatomically mimics the extensor central slip yet maintains the function of the donor FDS tendon. [24] (10.1016/j.jhsa.2009.01.025)
• [L5] The main goals of any treatment of a PIP joint complication are maintaining concentric reduction of the joint, restoring joint stability, and facilitating early range-of-motion exercises. [33] (10.1016/j.hcl.2017.12.014)
• [L4] Cortical breaks were commonly visualized in MCP and PIP joints with HR-pQCT and microCT. [37] (10.1186/s12891-016-1148-y)

References

[1] The relative motion concept in acute and chronic boutonniere deformity: Invited commentary. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.02.005 [2] Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.10.019 [3] Correction of the Rheumatoid Boutonnière Deformity. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00009 [4] Posttraumatic Boutonnière and Swan Neck Deformities. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00272 [5] Thumb boutonnière deformity without rheumatoid arthritis or trauma. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417704610 [6] Y-Shaped Tendon Graft—A Technique in the Reconstruction of Posttraumatic Chronic Boutonniere Deformity. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.01.003 [7] Fractional Fowler Tenotomy for Chronic Mallet Finger: A Cadaveric Biomechanical Study. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.07.039 [8] 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 [9] Treatment of Boutonniere Finger Deformity in Rheumatoid Arthritis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.029 [10] Operative Correction of Swan-Neck and Boutonniere Deformities in the Rheumatoid Hand. Journal of the American Academy of Orthopaedic Surgeons. 1999. DOI: 10.5435/00124635-199903000-00002 [11] Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200305000-00005 [12] Clarification of Extensor Tenotomy for Finger Deformities. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.07.008 [13] 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 [14] Swan Neck Deformity after Distal Interphalangeal Joint Flexion Contractures: A Biomechanical Analysis. Journal of Hand Therapy. 2010. DOI: 10.1016/j.jht.2009.11.005 [15] Finger Metacarpophalangeal Joint Injuries in Athletes: Evaluation, Diagnosis, Treatment, and Return to Play. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-21-01031 [17] A modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis: a cross-sectional analysis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419886719 [19] An in-depth look at zone III and IV anatomy of the finger extensor mechanism and some clinical implications for use of the relative motion flexion orthosis. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.01.002 [21] Finger Deformities Caused by Rheumatoid Arthritis. The Journal of Bone & Joint Surgery. 1957. DOI: 10.2106/00004623-195739030-00006 [24] Reconstruction of the Extensor Central Slip Using a Distally Based Flexor Digitorum Superficialis Slip. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.01.025 [33] Complications of Proximal Interphalangeal Joint Injuries. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.12.014 [37] Visual detection of cortical breaks in hand joints: reliability and validity of high-resolution peripheral quantitative CT compared to microCT. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1148-y