Orthoses For Rheumatoid Fingers

RICHARD D . KOCH, C . O .

DAVID A . BIRD, A . B . , C . O .

will l i m i t its s c o p e p r i m a r i l y t o t h e fitting

he boutonniere deformity o f the
o f o r t h o s e s f o r these t w o d e f o r m i t i e s ,
f i n g e r ( F i g . 1 ) , p r e v a l e n t with rh
a l o n g with s o m e considerations for a
e u m a t o i d arthritis, is c h a r a c t e r i z e d b y
t h u m b o r t(hPo. sI i. sP. . ) j o i n t a n d h y p e r t e n
f l e x i o n tightness o f t h e p r o x i m a linterphalangeal
s i o n o f t h e distal i n t e r p h a l a n g e a l ( D . I . P . )
W h y d o these d e f o r m i t i e s n e e d o r t h o t i c
j o i n t , a n d c a n usually b e h e l p e d b y a p p l i
t r e a t m e n t ? I n s o m e cases they d o n ' t ,
c a t i o n o f o r t h o s e s . T h e figuratively o p p o
b e c a u s e they s i m p l y c a n n o t b e c o r r e c t e d
site d e f o r m i t y , t h e swan n e c k ( F i g . 2 ) ,
(Fig.
3 ) . But m a n y
cases c a n b e
also c a n usually b e h e l p e d . T h i s p a p e r
c o r r e c t e d , a n d skeletal r e - a l i g n m e n t p r o
v i d e d b y a n orthosis allows m u c h relief

Fig. 1. an example of the boutonniere deformity.

Fig. 2. An example of the swan neck deformity.

Fig. 3. A boutonniere deformity that is not amen

able to correction by application of an orthosis.

from pain, reduces e d e m a , and provides

a d e t e r r e n t to further d e f o r m i t y , a n o t h e r
a d v a n t a g e f o r the p a t i e n t is greater use o f
the finger t h r o u g h stabilization, e v e n
t h o u g h P . I . P . f l e x i o n is p r e v e n t e d w h e n
the b o u t o n n i e r e orthosis ( F i g . 4 ) is u s e d .
M a n y types o f orthoses, f r o m the c r u d e t o
the s o p h i s t i c a t e d , h a v e b e e n used f o r the
t r e a t m e n t o f these t w o d e f o r m i t i e s , in
c l u d i n g off-the-shelf i t e m s , a n d s o m e o f

Fig. 4. Dorsal surface view of a "Boutonniere" or

thosis in place.

Fig. 5. A view of the

knuckle bender.

dynamic reverse finger

these h a v e b e e n successful. H o w e v e r , a
truly successful orthosis m u s t n o t o n l y
p r o m o t e a d e t e r r e n t to an i n c r e a s e in de
f o r m i t y , b u t must b e c o s m e t i c a l l y a c c e p t
able, nontoxic, and not bulky. N o t many
orthoses d e s i g n e d for these t w o d e f o r m i
ties m e e t these s t a n d a r d s ( 1 ) .
O b v i o u s l y , c o r r e c t i o n will n o t o c c u r
w h e n the orthosis is n o t w o r n , b u t m a n y
patients, n o m a t t e r h o w severe the de
f o r m i t y o r h o w great the p a i n , will refuse
to w e a r a finger orthosis that is b u l k y a n d
"uncosmetic".
F o r the p a t i e n t w i t h a severe b o u t o n
niere d e f o r m i t y , a d y n a m i c reverse finger
knuckle bender m a y b e used (Fig. 5 ) . for
the very severe, a n o u t r i g g e r i n v o l v i n g an
M P stop a n d a P . I . P . d y n a m i c e x t e n s i o n
unit m a y b e a p p r o p r i a t e ( F i g . 6 ) . A l l o f
these devices i n v o l v e the
three-pointpressure system n e e d e d to a c h i e v e stabili
zation and correction.

Fig. 6. An outrigger orthosis with an M.P. stop

and a P.I.P. dynamic extension unit.

T h e p r o c e d u r e f o r fitting b o u t o n n i e r e ,
swan n e c k , a n d t h u m b orthoses that
a c h i e v e c o r r e c t i o n are o u t l i n e d b e l o w .
T h e s e orthoses are light in w e i g h t a n d are
accepted from a cosmetic standpoint.
Fitting the Boutonniere Orthosis
T h e fitting o f orthoses f o r the fingers
involves the s a m e c a r e a n d p r o c e d u r e
c o m m o n to all orthoses f o r the trunk, cer
vical s p i n e , l o w e r a n d u p p e r l i m b s . T h e
three-point-pressure system is utilized,
c a r e b e i n g t a k e n to p r o v i d e the p r o p e r
c o n t o u r s a n d a v o i d u n d u e pressure o v e r
the fingers a n d h a n d .
T o reduce a boutonniere deformity,
the b o u t o n n i e r e r e d u c t i o n orthosis ( F i g .
7) is fitted w i t h the v o l a r p r o x i m a l b a n d
1 / 8 - i n . distal to the w e b s p a c e . T h e distal
v o l a r b a n d is p l a c e d at the D . I . P . j o i n t
a n d the d o r s a l b a n d is l o c a t e d o v e r the
P . I . P . j o i n t so as to a p p l y pressure o n the

Fig. 7. A schematic showing system of forces provided by the "boutonniere" orthosis. Courtesy of Camp In
ternational, Inc.

d o r s a l s u r f a c e . T h e orthosis s h o u l d b e
c o n t o u r e d so that pressure f r o m the distal
b a n d tends to flex the D . I . P . j o i n t w i t h
the P . I . P . j o i n t b e i n g h e l d in the c o r
rected position (Fig. 8 ) .
Fitting the S w a n N e c k Orthosis
T h e s w a n n e c k orthosis is o f t e n a b o u t
o n n i e r e orthosis r o t a t e d 180 d e g , b u t
specially d e s i g n e d o r t h o s e s are o f t e n used
as well ( F i g s . 9 a n d 1 0 ) . the p r o x i m a l d o r
sal b a n d s h o u l d b e 1/8-in distal t o the
M P j o i n t a n d m u s t n o t i m p i n g e o n the
P . I . P . j o i n t . T h e distal e d g e o f the distal
d o r s a l b a n d s h o u l d b e at the D . I . P . j o i n t

a n d the b a n d m u s t n o t i m p i n g e o n the
P.I.P. joint. T h e volar b a n d should be
just p r o x i m a l to the P . I . P . j o i n t so as to
a l l o w P . I . P . f l e x i o n w i t h the orthosis
w h i l e P . I . P . e x t e n s i o n is restricted. T h e
v o l a r pressure a p p l i e d b y the distal b a n d
w h i l e P . I . P . e x t e n s i o n is a t t e m p t e d en
c o u r a g e s D . I . P . e x t e n s i o n ( F i g . 11 a n d
12).
Fitting the T h u m b Orthosis
T h e orthosis f o r d e f o r m i t i e s o f the IP
j o i n t in h y p e r e x t e n s i o n a n d M P j o i n t
( F i g . 1 3 ) in f l e x i o n stabilizes a n d p l a c e s
the t h u m b in a f u n c t i o n a l p o s i t i o n ( F i g .

1 4 ) . T h e orthosis is c o n t o u r e d to the
t h u m b . Pressure is a p p l i e d to the M P
j o i n t w h i l e the b a n d is b r o u g h t a r o u n d in
c o n t o u r so as to a p p l y pressure in a dorsal
d i r e c t i o n , thus c a u s i n g the I P j o i n t to
flex. T h e b a n d s h o u l d b e p r o x i m a l t o the
IP j o i n t b u t n o t c a u s e i m p i n g e m e n t in the
w e b s p a c e . T h e third p o i n t o f pressure is
the wrist strap w h i c h applies a laterally
directed force.
Discussion
W h e n treating r h e u m a t o i d
arthritis
w i t h intrinsic h a n d d e f o r m i t i e s , it is diffi
cult to k e e p it s i m p l e a n d at the s a m e
t i m e p r o v i d e an orthosis that is a c c e p t
a b l e f r o m the c o s m e t i c s t a n d p o i n t .

Fig. 8. A palmar view of the "boutonniere" ortho

sis. Flexion of the D.I.P. joint is allowed while the
P.I.P. joint is held in the corrected position.

W i t h the b o u t o n n i e r e a n d swan n e c k
d e f o r m i t i e s that are c o r r e c t a b l e , a r e d u c
t i o n o f p a i n a n d e d e m a will usually f o l l o w
w h e n a well fitting, c o r r e c t l y d e s i g n e d o r
thosis is a p p l i e d . S u c h an orthosis m u s t b e
light, n o n t o x i c , n o t b u l k y , a n d c o s m e t i
cally a c c e p t a b l e . It m u s t b e c a p a b l e o f
b e i n g adjusted easily w i t h o u t fear o f

Fig. 9. A schematic showing the system of forces provided by the "swan neck" orthosis. Courtesy of Camp In
ternational, Inc.

Fig. 10. Medial view o f the "swan neck" orthosis. It

can be fashioned from a tube o f either aluminum
or plastic.

or

deforming

stainless

breaking

steel

orthosis

the

orthosis.

orthotic

principles not only meets

designed

around
these

r e q u i r e m e n t s b u t will b e s e r v i c e a b l e

for

m a n y years.
A stainless steel orthosis f o r these

two

d e f o r m i t i e s is a v a i l a b l e f r o m C a m p I n t e r
national,

Inc. T h e a l u m i n u m or

plastic

t u b e f o r s w a n n e c k c o r r e c t i o n is m o r e dif
ficult

to a d j u s t a n d w i t h t h e

aluminum

Fig. 11. A volar view o f a "swan neck" orthosis.

Flexion o f the P . I . P . joint is allowed while exten
sion is restricted.

Fig. 12. A dorsal view of a "swan neck" orthosis.

T h e distal band encourages extension o f the D . I . P .
joint.

Fig. 13. A n example of the boutonniere deformity

in the t h u m b .

Fig. 14. View of the "thumb boutonniere" orthosis in p l a c e .

orthosis,

breakage is a factor.

With

plastic orthosis bulk definitely is a prob

lem.
For

the t h u m b orthosis stainless steel

University of Michigan Hospital

Ann Arbor, Michigan 48109
2David A . Bird, A . B . , C . O .
University of Michigan Hospital
Ann Arbor, Michigan 48109

has been found to be the best material for

the reasons stated above.
Credit should be given to Ben C . Fow
ler, C . O . , for his early work in this area.
Footnotes
1Richard D . Koch, C . O .
Director of Orthotics and Prosthetics

References
(1) Bennett, Robert L . , "Orthotic devices to pre
vent deformities on the hand in rheumatoid arthri
tis," Arthritis and Rheumatism, 1:5, Oct. 1965.
(2) Cailliet, Rene, Hand Pain and Impairment,
Chapter V , p. 120.