Boutonniere Deformity

Other Names

• Buttonhole deformity
• Boutonniere Deformity (BD)
• Traumatic Boutonniere Deformity
• Atraumatic Boutonniere Deformity
• Boutonnière Deformity of the Finger

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Background

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

History

• Note that 'Boutonniere' is French for buttonhole

Epidemiology

• Needs to be updated

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Introduction

Clinical Example of Boutonniere Deformity

Illustration of Boutonniere Deformity

Illustration of Boutonniere Deformity

General

• Zone 3 injury to the central slip, resulting flexion of PIP joint, extension of DIP joint
• Diagnosis is primarily clinical, Elsons Test is often positive
• Acute management is typically nonoperative with splinting
• Chronic, symptomatic cases may require surgical intervention

Pathoanatomy

• Zone 3 injury to the central slip causing
  • Deformity characterized by flexion of the PIPJ, extension or hyperextension of the DIPJ
  • Less commonly, MCP joint extension may occur
• Thumb: BD occurs the metacarpophalangeal (MCP) joint
  • Resulting in an extended MCPJ and flexed IPJ
• Fingers 2-4: occurs at the proximal interphalangeal (PIP) joint
  • Resulting in a pathologic flexion at the PIPJ and hyperextension at the DIPJ

Etiology

• Occurs as a result of a Central Slip Extensor Tendon Injury
  • Results in flexion contracture of PIPJ and hyperextension of DIPJ
• Acute
  • Direct laceration to extensor tendon
  • Jammed finger
• Chronic
  • Rheumatoid Arthritis
  • Burns
  • Dupuytrens Contracture

Pathogenesis and Anatomy

• The pathology starts with an injury to the Central Slip
• This runs dorsally over the PIP joint where the extensor tendon attaches to the middle phalanx
• Rupture of the central slip starts a cascade of events
  • Extrinsic mechanism of extensor digitorum, resulting in loss of extension at PIPJ
  • When rupture/ injury occur, the PIPJ "buttonholes" through the defect in the slip
• This results in stretching or tearing of the triangular ligament
  • Subsequently, there is volar/palmer migration of the lateral bands
  • This causes lumbricals of the hand to act as flexors at the PIPJ
• Over time, the DIPJ will be pulled into extension
  • This occurs from the lumbricals too as there is loss of an opposing force
• Bone deformities
  • The middle phalanx flexes on the proximal phalanx at the PIPJ
  • The distal phalanx is extended/hyperextended relative to middle phalanx at the DIPJ

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Risk Factors

Chronic Disease

• Rheumatoid Arthritis
  • Approximately 50% of patients with RA will develop a BD
• Dupuytrens Contracture

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Differential Diagnosis

Differential Diagnosis Finger And Hand Pain

• Fractures
  • Phalanx Fractures of the Hand
  • Metacarpal Fractures
    • Boxers Fracture
    • Rolando Fracture
    • Bennett Fracture
• Dislocations
  • Metacarpophalangeal Joint Dislocation
  • Interphalangeal Joint Dislocation (Proximal and Distal)
  • Carpometacarpal Joint Dislocation
• Tendinopathies
  • Extensor Tendon Injuries of the Hand
  • Central Slip Extensor Tendon Injury
  • Flexor Tendon Injuries of the Hand
  • Boutonniere Deformity
  • Swan Neck Deformity
  • Jersey Finger
  • Mallet Finger
  • Trigger Finger
  • De Quervains Tenosynovitis
  • Volar Plate Avulsion Injury
  • Sagittal Band Injury
  • Mannerfelt Lesion (FPL Rupture)
• Ligament Injuries
  • Gamekeepers Thumb (UCL)
  • Radial Collateral Ligament of the Thumb Injury (RCL)
• Neuropathies
  • Wartenbergs Syndrome
  • Carpal Tunnel Syndrome
  • Guyon Canal Syndrome
• Arthropathies
  • Carpometacarpal Arthritis
  • Finger Arthritis
  • Rheumatoid Arthritis
• Nail Bed Injuries
  • Nail Bed Lacerations
  • Nail Bed Avulsions
  • Subungual Hematoma
  • Paronychia
  • Felon
• Pediatric Considerations
  • Proximal Phalanx Avulsion Fracture (Thumb)
  • Middle and Distal Phalanx Avulsion Fracture
• Other
  • Dupuytrens Contracture
  • Intrinsic Plus

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Clinical Features

Clinical example of Elson's Test

History

• Important to clarify etiology
• Is it acute, subacute or chronic?

Physical Exam: Physical Examination Hand

• The resting position of the finger should 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

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Evaluation

Boutonniere Deformity of the 5th digit seen on lateral view (etiology unknown)

Radiology

• Standard Radiographs Hand
  • Typically satisfactory to evaluate
  • Can evaluate degree of flexion (PIPJ) and hyperextension (DIPJ)
  • Also can help clarify etiology

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Classification

Burton Classification

• Stage 1: BD with supple, passively correctable joint
• 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

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Management

Examples of splints for keeping the PIPJ in extension

Acute, Nonoperative

• Indications
  • Absence of avulsion fracture
  • Small avulsion fracture, nondisplaced
  • Acute closed injuries (typically less than 4 weeks)
• Extension splinting of PIPJ for 4-6 weeks
• Encourage active DIPJ extension and flexion in splint

Acute, Operative

• Indications
  • Avulsion fracture of middle phalanx
  • Open injury
• Technique
  • Lateral band relocation
  • Terminal tendon tenotomy
  • Tendon reconstruction

Chronic, Nonoperative

• Most cases can be managed nonoperatively
• Corticosteroid Injections

Chronic, Operative

• Indications
  • Rheumatoid patients
  • Painful, still and arthritic joint
• Technique
  • Arthrodesis

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Rehab and Return to Play

Rehabilitation

• Goals of rehab
  • Reduce pain, edema
  • Reduce MCP, PIP, DIP joint ROM/joint contracture
  • Improve hand function, grip and pinch

Return to Play/ Work

• Needs to be updated

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Prognosis and Complications

Prognosis

• Needs to be updated

Complications

• Functional debilitation
• Chronic Pain

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See Also

Internal

• Hand and Wrist Anatomy (Main)
• Finger Pain (Main)
• Hand Pain (Main)

External

• https://www.sportsmedreview.com/blog/review-of-the-traumatic-boutonniere-deformity/

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