Boutonniere Deformity


Article Author:
Justin Binstead


Article Editor:
Jason Hatcher


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/8/2019 1:46:39 PM

Introduction

Boutonniere deformity describes a medical condition in which the finger is flexed at the proximal interphalangeal joint (PIP), and there is hyperextension at the distal interphalangeal joint (DIP). This is usually a result of trauma in the acute setting and is caused by force applied to the top of a bent middle joint of a finger. There is a direct injury to the central slip that damages the extensor function of the affected digit. A boutonniere deformity can also result from a laceration on the top of a finger, which can sever the tendon and detach it from the bone. It can also happen if the patient would suffer a full-thickness burn resulting in direct injury to the central slip.  However, more commonly, it's secondary to an inflammatory condition, such as rheumatoid arthritis.[1]

Etiology

Injury to the extensor tendon causes this flexion deformity of the proximal interphalangeal joint. The extensor tendon is disrupted and the lateral aspects of the tendon separate. The head of the proximal phalanx projects through this disrupted area. The deformity garnished its name because the injury caused the proximal phalanx to protrude through like a finger through a buttonhole (hence the name, from French boutonniere, which translates into buttonhole).[2] Football and basketball are the most common source of sports-related boutonniere deformities.

Epidemiology

A small number of emergency department diagnosed patients with jammed or sprained finger will eventually have boutonniere deformity. Up to half or 50% of patients with rheumatoid arthritis develop a boutonniere deformity in at least one digit.[3]

Pathophysiology

A boutonniere deformity results when the triangular ligament and the central slip of the extensor tendon of a digit are disrupted. This disruption of the ligament and tendon will cause the lateral bands to the volar surface of the finger. This will result in forced flexion of the finger, and then the dorsal interphalangeal joint will experience difficulty in extension. Over time, the oblique retinacular ligament will contract. This ligament contracture will gradually worsen the hyperextension deformity of the joint.[4] The pathophysiology is different if it is secondary to rheumatoid arthritis. Inflammatory cells collect in the synovial fluid of the joint which forms a layer of fibrous tissue. This leads to bony erosion and damage to cartilage and ligaments. The joints gradually deform which leads to loss of function and pain.

History and Physical

A thorough history and physical should be obtained to determine the mechanism of injury to the affected digit. It is important to recognize the type and extent of the injury as treatments options are varied depending on injury pattern. It is also necessary to prevent long-term complications and deformities from these injuries. It is usually one of the injuries associated with a “jammed finger.” Symptoms can be immediate or delayed for several weeks. If the injury occurs as a result of a laceration, the area needs to be thoroughly cleaned and examined in a “bloodless field” for tendon integrity. This can easily be accomplished by using a glove. Simply cut the finger off a glove and place on the affected digit and then cut a small hole at the distal aspect of the finger glove. Then, roll the finger glove proximally until it forms a “ring” at the base of the digit which will function as a tourniquet. The condition of the tendon will determine treatment options.

If rheumatoid arthritis causes a boutonniere deformity, a thorough history should include the duration of symptoms, medications (both previous and current), level of pain and degree of disability.[5]

Evaluation

X-rays are indicated to determine if there are any associated fractures. It is also important to identify any disruption of the bones that attach to the central slip of the tendon. Lateral radiographs can be used to determine the degree of hyperextension.

Treatment / Management

The goal of treatment is to regain full range of motion of the affected finger. Treatment options include both surgical and nonsurgical modalities. Splinting is a nonsurgical treatment and involves immobilizing the affected joint to allow for straightening to occur. This also allows the tendon to heal and not continue to separate. Splints are usually maintained for 3 to 6 weeks depending on the patient’s age and severity of the injury. Often patients will be instructed to wear the splint at night for several more weeks. Management should also include exercises to improve the strength and flexibility of the affected digit. If the injury is a result of sports activity, the affected area may be taped or have other protective splinting applied to protect it further if resuming activities. Surgical correction can occur if the tendon is severed or if there is a significant bone fragment displaced from its normal position of function.[6] It may also be an option if it does not improve with conservative measures, such as splinting. If a large avulsion is present, surgical fixation with a wire or screw is used to correct for the extensor injury. The deformity becomes more difficult to correct if the deformity has been left untreated for greater than three weeks.

The treatment options for a boutonniere deformity vary if it is a result of sequelae of rheumatoid arthritis. The classes of medications to treat rheumatoid arthritis are disease-modifying anti-rheumatic drugs (DMARDs), biologic response modifiers, glucocorticoids, nonsteroidal anti-inflammatory medications (NSAIDs), and analgesics. DMARDs are used to delay the progression of rheumatoid arthritis. DMARDs have different mechanisms of action and are often used in combination therapy. Although the mechanism of action varies, they have the similar impact of the disease process. Biologic response modifiers are genetically engineered and work by interrupting a patient’s immune system signals that are responsible for tissue damage. Most of these medications attempt to interfere with the activity of tumor necrosis factor. Glucocorticoids are used to reduce inflammation and also to curb the autoimmune activity. They are often used in conjunction with DMARDs. NSAIDs can aid with pain control, swelling, and inflammation, but do not affect slowing the disease process. Analgesics are used to control pain only. 

If nonsurgical measures are unsuccessful, surgical joint replacement may be necessary. Joint fusion is another surgical procedure that involves fusing the two joint surfaces of the affected digit together. The benefits of joint fusion are pain improvement, increased the stability of the joint, and prevention of worsening joint deformity. After surgery, patients are instructed to wear a splint or brace for several weeks to keep the proximal interphalangeal joint straight.[3] Physical or occupational therapy often follows splinting.

Enhancing Healthcare Team Outcomes

The diagnosis and management of boutonniere deformity is complex and requires a multidisciplinary team that includes a primary care provider, nurse practitioner, physical therapist, hand surgeon, and orthopedic surgeon. The goal of treatment is to regain full range of motion of the affected finger. Treatment options include both surgical and nonsurgical modalities.  If nonsurgical measures are unsuccessful, surgical joint replacement may be necessary. Joint fusion is another surgical procedure that involves fusing the two joint surfaces of the affected digit together. The benefits of joint fusion are pain improvement, increased the stability of the joint, and prevention of worsening joint deformity. After surgery, patients are instructed to wear a splint or brace for several weeks to keep the proximal interphalangeal joint straight.[3] Physical or occupational therapy often follows splinting. The outcomes for boutonniere deformity are guarded. While recovery is possible, it may take a long time to improve range of motion and function.[7][8] (Level V)


  • Image 7217 Not availableImage 7217 Not available
    Contributed by Steve Bhmiji, MD, MS, PhD
Attributed To: Contributed by Steve Bhmiji, MD, MS, PhD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Boutonniere Deformity - Questions

Take a quiz of the questions on this article.

Take Quiz
Which band is associated with a boutonniere deformity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is a characteristic of a boutonniere deformity of the fingers?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which description below describes an affected joint in the Boutonniere deformity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not seen with the Boutonniere deformity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 44 year old patient with severe rheumatoid arthritis of the hands presents with worsening swelling in her hands. Her right long finger is extended at the DIP joint and hyperflexed at the PIP joint. What is the name of this condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Boutonniere Deformity - References

References

Biomechanics of the Acute Boutonniere Deformity., Grau L,Baydoun H,Chen K,Sankary ST,Amirouche F,Gonzalez MH,, The Journal of hand surgery, 2017 Sep 7     [PubMed]
Boutonnière Deformity Following Volar Proximal Interphalangeal Joint Dislocation., Sood A,Kotamarti VS,Granick MS,, Eplasty, 2016     [PubMed]
Vedel PN,Tranum-Jensen J,Dahlin LB,Brogren E,S�e NH, [Deformities of the finger joints]. Ugeskrift for laeger. 2017 Nov 27     [PubMed]
Bai RJ,Zhang HB,Zhan HL,Qian ZH,Wang NL,Liu Y,Li WT,Yin YM, Sports Injury-Related Fingers and Thumb Deformity Due to Tendon or Ligament Rupture. Chinese medical journal. 2018 May 5     [PubMed]
Sharif K,Sharif A,Jumah F,Oskouian R,Tubbs RS, Rheumatoid arthritis in review: Clinical, anatomical, cellular and molecular points of view. Clinical anatomy (New York, N.Y.). 2018 Mar     [PubMed]
Fox PM,Chang J, Treating the Proximal Interphalangeal Joint in Swan Neck and Boutonniere Deformities. Hand clinics. 2018 May     [PubMed]
Hirth MJ,Howell JW,O'Brien L, Relative motion orthoses in the management of various hand conditions: A scoping review. Journal of hand therapy : official journal of the American Society of Hand Therapists. 2016 Oct - Dec;     [PubMed]
McKeon KE,Lee DH, Posttraumatic Boutonnière and Swan Neck Deformities. The Journal of the American Academy of Orthopaedic Surgeons. 2015 Oct;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Elder Adult Care. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Elder Adult Care, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Elder Adult Care, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Elder Adult Care. When it is time for the Nurse-Elder Adult Care board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Elder Adult Care.