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Boutonniere Deformity

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Other Names

  • Buttonhole deformity
  • Boutonniere Deformity (BD)


  • This page refers to a Boutonniere Deformity, which is a zone 3 central slip injury


  • Note that 'Boutonniere' is French for buttonhole



Illustration of Boutonniere Deformity[1]
  • General
    • Zone 3 injury to the central slip
    • Resulting in a pathologic flexion at the PIPJ and hyperextension at the DIPJ



Risk Factors

Differential Diagnosis

Clinical Features

Clinical Example of Boutonniere Deformity[2]
  • History
    • Important to clarify etiology
    • Is it acute, subacute or chronic?
  • Physical Exam: Physical Examination Hand
    • The resting position of the finger may be PIPJ in flexion with DIPJ in extension
  • Special Tests
    • Elson's Test can help confirm central slip injury
    • Boyes Test is also useful to evaluate extensor tendon integrity


Boutonniere Deformity of the 5th digit seen on lateral view (etiology unknown)[3]
  • Standard Radiographs Hand
    • Typically satisfactory to evaluate
    • Can evaluate degree of flexion (PIPJ) and hyperextension (DIPJ)
    • Also can help clarify etiology


Burton Classification

  • Stage 1: BD with supple, passively correctable joint[4]
  • Stage 2: BD with fixed contracture, contracted lateral bands, PIPJ maintained
  • Stage 3: BD with fixed deformity, contracture of lateral bands, volar plate and collateral ligaments; PIPJ with intra-articular fibrosis
  • Stage 4: BD with fixed deformity, contractures of lateral bands, volar plate and collateral ligaments; PIPJ with intra-articular fibrosis and radiographically evident degenerative arthritis


Acute, Nonoperative

  • Extension splinting of PIPJ for 4-6 weeks
  • Encourage active DIPJ extension and flexion in splint
  • Indications
    • absence of avulsion fracture
    • Small avulsion fracture, nondisplaced

Acute, Operative

  • Indications
    • Avulsion fracture of middle phalanx
    • Open injury

Chronic, Nonoperative

  • Most cases can be managed nonoperatively

Chronic, Operative

  • Rheumatoid patients
  • Painful, still and arthritic joint

Rehab and Return to Play


  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis


  • Needs to be updated


  • Functional debilitation
  • Chronic Pain

See Also



  1. Image courtesy of osmifw.com, "Boutonnière Deformity
  2. Image courtesy of verywellhealth.com, "Boutonniere Deformity"
  3. Contributed by Dr.Rebecca Flores.
  4. McKeon, Kathleen E., and Donald H. Lee. "Posttraumatic boutonniere and swan neck deformities." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 23.10 (2015): 623-632.
Created by:
John Kiel on 18 June 2019 23:23:34
Last edited:
16 October 2022 00:18:26