钮扣孔畸形资料 In-depth

您的感受

钮扣孔畸形（Boutonnière deformity）会改变您某根手指的弯曲方式。手指的中节关节（近端指间关节）持续向下弯曲，而末端关节（远端指间关节）则向上翘起，无法弯曲。这种情况发生在手指背侧一条细小、扁平的肌腱（中央腱束）停止正常工作时。该肌腱通常负责伸直中节关节。当它发生撕裂、拉伸或磨损断裂时，手指便无法在该处伸直。

手指可能会感到疼痛，并导致手部使用变得非常困难。需要手指伸直的任务会变得艰难。戴手套、打字、握笔或捡拾硬币等动作都可能感觉别扭或不舒适。任何压迫弯曲关节的动作，如握方向盘或提购物袋的手柄，都可能加剧疼痛。让手部休息并保持手指静止通常能缓解症状。

这种畸形在类风湿关节炎患者中很常见，其中节关节内持续的肿胀（滑膜炎）会缓慢磨损该肌腱。约36%的确诊类风湿关节炎患者存在钮扣孔畸形，且约有一半患者会发展为钮扣孔畸形或天鹅颈畸形。它也可能继发于外伤，例如切割伤或手指背侧的猛烈撞击损伤了中央腱束。

肿胀和疼痛通常遵循一定的规律。关节在晨起时可能感觉僵硬和酸痛，随着开始活动会略微缓解。经过一天频繁使用手部后，手指可能会酸痛，且弯曲程度比平时更明显。当手指过度劳累时，夜间关节搏动性疼痛也很常见。

有一点值得了解：早期发现至关重要。如果中央腱束损伤在发生后得到及时治疗，通常可以完全防止畸形的发生。

实际发生了什么

可以将手指背侧的肌腱想象成一根沿顶部走行、并在近中节指间关节附近分裂成束的绳索。其中一束，即中央腱束，附着于中间指骨并伸直该关节。另外两束沿其两侧走行。正常情况下，这三束协同工作，由覆盖在关节上的薄层组织固定，如同拉紧的缆绳将帐篷杆保持直立。

当手指受伤，或类风湿关节炎从关节内部侵蚀肌腱时，中央腱束可能发生撕裂或过度拉伸。一旦其脱离附着点，两侧腱束便会滑至关节下方，而非沿顶部走行。由此，它们将中间关节向下牵拉至屈曲位置，而非使其伸直。这就是为什么您的手指在中节指间关节处呈屈曲状态，而末端指间关节呈背伸状态。

产生这种畸形需要多个结构同时受损。中央腱束、固定腱束的薄层组织以及周围的部分纤维均须受到影响，腱束才会实际滑脱移位。这也是为什么在完全畸形形成之前，手指早期可能在中节指间关节处出现弹响或卡顿感。

还有一点值得了解。一旦畸形存在时间较长，关节本身会僵硬并适应其屈曲位置。即使经过治疗，中节指间关节仍可能残留几度的伸直功能丧失。这就是为什么早期治疗至关重要，正如上文所述。

我们能做什么

Mater Private Hospital Rockhampton 的上肢外科医生 Kieran Hirpara 博士会从适合您病情的最微创方案入手。患者通常由全科医生（GP）转诊至我们的诊所；如果物理治疗师建议您就诊，您仍需获得全科医生的转诊才能符合 Medicare 报销资格。在您的首次就诊时，我们会采集病史，检查您的手指，并仅在影像学检查会改变诊疗计划时安排相关检查。细致的检查是引导我们选择正确检查手段和正确治疗方案的关键。

对于已存在一段时间的畸形，我们通常从支具固定开始。一旦手指已被保持伸直足够长的时间，您将佩戴一种支具，该支具将手指保持在特定位置，使您能够继续使用手部。您需要佩戴 3 个月。当最初的支具固定已将中间关节（近端指间关节）矫正至小于 -20° 的伸展位（即能够伸直至距完全伸直还有 20 度的位置）时，此方法有效，且您需在整个过程中主动使用支具。在受伤后 6 周内开始治疗，对恢复的活动度有显著影响。对于新鲜的中央滑车腱损伤，我们将手指的中间关节保持在完全伸直位（完全伸直）4 周，同时末端关节保持活动，随后使用弹簧加载支具再固定 2 周。在此期间的大部分时间，您仍可使用手部进行轻度活动。

如果支具固定未能提供足够的伸直效果，手术是下一步。当肌腱损伤超出支具可修复的范围，或畸形已固定时，我们会考虑手术。手术旨在重建手指背侧的肌腱机制，使其能够再次伸直中间关节。如果肌腱的侧束磨损或受损，我们可以使用您自身手腕处的一条肌腱进行重建。每种手术的具体细节都有专门的页面介绍，在做出任何决定之前，我们会与您详细讨论哪种手术适合您的手指。

预期情况

恢复效果在很大程度上取决于手指治疗的及时性。如果新鲜的中央滑车腱损伤能尽早接受夹板固定，畸形往往可以被完全预防。若未予处理，中间关节通常会保持屈曲状态，并可能随时间推移而固定在该位置。一旦畸形持续存在较长时间，即使接受良好治疗，手指也可能无法完全伸直，存在几度的屈曲残留。

对于已经固定的畸形，初始步骤是通过石膏固定来矫正中间关节，随后在持续使用手部的同时佩戴夹板3个月。当石膏能将关节矫正至小于-20°的伸展位（即比完全伸直状态少20度的位置）时，此方法有效。在这3个月期间，您需要在佩戴夹板的同时主动使用手部，以恢复屈曲活动。这是一个缓慢的过程，且需要您的配合：只有当您实际在佩戴夹板时活动手指，夹板才能发挥作用。

当夹板固定达到其最大效果后，手术是下一步治疗。在腱侧束磨损或受损的部位，可以使用您自身腕部的一条腱组织进行重建。对于长期存在的畸形接受该手术的患者，18例中有16例疗效良好或极佳。针对长期畸形的另一种选择是在末端关节处切断腱，接受该手术的患者功能障碍显著减轻，且该关节的屈曲功能得到恢复。

几点诚恳的提示。在该畸形的后期阶段，仅靠软组织手术可能无法永久维持矫正效果。此外，如果您患有类风湿关节炎，随着基础疾病的进展，手指畸形可能会持续发展，因此您的治疗方案将综合评估关节的固定程度、活动情况以及关节面的状态。这并不意味着手术无法提供帮助，而是意味着治疗目标是获得功能更好的手指，而非承诺手指完全笔直。

何时就医

如果手指开始在中间关节处弯曲且无法伸直，尤其是如果您患有类风湿性关节炎，请咨询您的全科医生。如果中间关节疼痛、出现卡顿或弹响，或者手指在日常任务中越来越难以使用，请要求专科医生评估。这些变化可能缓慢出现，因此很容易被归因于过度使用。时机很重要：在受伤后6周内开始治疗，对恢复活动度有显著影响；一旦畸形存在时间过长，纠正难度会大大增加。如果您注意到一根手指在中间关节处向下弯曲，而末端关节向上翘起，请不要等待其自行缓解。

深入探讨

Advanced reading: the deeper science (optional)

本节内容超出了您自行做出治疗决策所需的深度。钮扣孔样畸形值得额外阅读，因为对于疼痛、肿胀且弯曲的手指，直觉上的处理方式——让整个手指休息并使其完全静止——并不是证据所支持的做法：应保持中间关节伸直，同时让末端关节保持活动。

早期活动，而非长期固定

一项关于中央滑车损伤治疗的系统综述发现，其证据基础有限，对于开放性和闭合性损伤的不同策略的作用缺乏充分支持 [1]。在此局限性范围内，来自个体研究的证据初步支持早期活动，不支持长期固定 [1]。

这一点值得明确陈述，因为它违背了本能反应。其区别在于保护愈合中的中央滑车（这需要保持中间关节伸直）与固定整个手指（这会导致指尖关节在伸直位僵硬，并使整个手指变得僵硬）。夹板的目的是固定一个关节，同时让其他关节保持活动。

为何畸形会进行性加重而非保持静止

钮扣孔畸形（Boutonnière deformity）是一种进行性畸形，这一点较为罕见且值得深入理解。中央腱束附着于中节指骨基底，负责伸直中间关节（近端指间关节）。当其功能失效时，该关节陷入屈曲位，而两条侧腱束——正常情况下走行于关节轴线上方——则滑移至轴线下方。

一旦侧腱束位于轴线下方，原本辅助伸直中间关节的同一组肌腱便开始使其屈曲，同时将指尖拉入过伸位。因此，该畸形具有自我强化特性：任何试图伸直手指的努力都会使当前维持其屈曲位的结构进一步收紧。这正是为何看似轻微的外伤可能在数周后导致固定性畸形，以及为何简单夹板固定的有效窗口期仅限于早期。

非钮扣孔样畸形

手指可在完全没有中央滑车损伤的情况下呈现相同的姿势，且治疗方案截然不同。钮扣孔样畸形与假性钮扣孔样畸形在病理解剖、诊断及治疗上均存在差异 [2]，其中假性类型源于中节指间关节的掌板损伤，此时远端指间关节保留正常的被动屈曲功能，而非被牵拉至过伸位。

床旁鉴别二者关键在于远端指间关节。在真性钮扣孔样畸形中，远端指间关节处于过伸位且抵抗屈曲，尤其在中节指间关节伸直时更为明显；而在假性钮扣孔样畸形中，远端指间关节可自由屈曲。若将假性钮扣孔样畸形误当作真性畸形进行夹板固定，则针对了错误的关节。

它属于一类由肌腱失效部位所定义的损伤

钮扣指畸形（Boutonnière）与锤状指（mallet finger）及矢状带损伤（sagittal band injury）并列为三种闭合性伸肌机制损伤之一，这些损伤根据机制失效的分区（zone）进行分类 [3]。这三种损伤均可能在受伤后数天内表现为肿胀的手指并处于异常姿势，且每种损伤都需要不同的夹板固定位置，这正是为何在决定进行数周夹板固定之前，值得做出明确诊断的实际原因。

参考文献

[1] Geoghegan L, Wormald JCR, Adami RZ, Rodrigues JN. 中央滑车伸肌腱损伤：治疗方法的系统综述。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. 纽扣孔畸形与假纽扣孔畸形：病理解剖、诊断与治疗。J Hand Surg Am. 2023;48(5):489-97. https://doi.org/10.1016/j.jhsa.2022.10.019

[3] Lin JD, Strauch RJ. 闭合性软组织伸肌装置损伤（锤状指、纽扣孔畸形及矢状带损伤）。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

[1] Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.10.019

[2] Posttraumatic Boutonnière and Swan Neck Deformities. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00272

[3] BOUTONNIERE DEFORMITY. Hand Clinics. 1995. DOI: 10.1016/s0749-0712(21)00060-3

[4] 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

[5] Correction of the Rheumatoid Boutonnière Deformity. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00009

[6] A Paradigm Shift in Managing Acute and Chronic Boutonniere Deformity. Annals of Plastic Surgery. 2020. DOI: 10.1097/sap.0000000000002307

[7] 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

[8] Restoration of the Central Slip in Congenital Form of Boutonniere Deformity: Case Report. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.030

[9] Chronic Boutonniere Deformity: Cross-Lateral Band Technique Using Palmaris Longus Autograft. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.04.010

[10] Extensor Tenotomy for Chronic Boutonniere Deformity of the Finger: REPORT OF TWO CASES.. The Journal of Bone and Joint Surgery. American Volume. 1965.

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

[12] Assessment of the ligamentous stress distribution in the pathomechanics of the boutonniere deformity through a computational 3D model. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06329-3

[13] TREATMENT OF THE CHRONIC BOUTONNIERE DEFORMITY BY EXTENSOR TENOTOMY. Hand Clinics. 1995. DOI: 10.1016/s0749-0712(21)00065-2

[15] Biomechanics of the Acute Boutonniere Deformity. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.07.011

[16] 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

[18] Anterior dislocation of the proximal interphalangeal joint. A cause of rupture of the central slip of the extensor mechanism.. The Journal of bone and joint surgery. American volume. 1970.

[19] Boutonnière and Pulley Rupture in Elite Athletes. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.05.044

[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