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Boutonniere Deformity

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Other Names

  • Buttonhole deformity
    • Note that 'Boutonniere' is French for buttonhole
  • BD


  • Zone 3 injury to the central slip
  • Resulting in a pathologic flexion at the PIPJ and hyperextension at the DIPJ


Risk Factors

  • Unknown

Differential Diagnosis

Clinical Features

  • General: Physical Examination Hand
  • Important to clarify etiology
    • Is it acute, subacute or chronic?
  • Physical Exam
    • The resting position of the finger may be PIPJ in flexion with DIPJ in extension
    • Elson's Test can help confirm central slip injury
    • Boyes Test is also useful to evaluate extensor tendon integrity
  • A thorough neurovascular exam should be performed


  • 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[1]
  • 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

Return to Play

  • Needs to be updated


  • Functional debilitation
  • Chronic Pain

See Also


  1. 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:
28 October 2020 13:53:21