Boutonnière

Deformity

Dr. Himanshu Singh

MBBS, D.Ortho
DNB resident
HOSMAT Hospital Bangalore
Introduction
• A boutonnière (buttonhole)
deformity (BD) may develop
either in the acute setting
(secondary to trauma) or
progressively (secondary to
arthritis). 

• The term is used to describe the

clinical scenario in which a
patient’s finger exhibits
pathologic
• flexion at the proximal
interphalangeal (PIP) joint
• and hyperextension at the
distal interphalangeal (DIP)
joint
Pathoanatomy

Normal lateral band location, dorsal to axis After central slip disruption, lateral bands
of rotation of proximal interphalangeal migrate volar to axis of rotation of proximal
joint.  interphalangeal joint. 
Pathoanatomy
Disruption of the central slip, DIP
joint - extensor lag;
Under the pull of the lumbrical
and interosseous muscles,
the untethered conjoint lateral
bands contract and eventually
create a pathologic extension
force across the DIP joint. This
occurs as the triangular ligament
becomes further attenuated and
the transverse retinacular
ligaments contract.
With the DIP joint in
hyperextension, the oblique
retinacular ligament, which is
located at the dorsal DIP joint, will
contract over time, contributing
to the hyperextension deformity
of this joint.
Boutonnière Deformity

• A Zone III extensor

tendon injury
characterized by
• PIP flexion
• DIP extension
• Mechanism
• rupture of the central slip
over PIP joint from
• laceration
• traumatic avulsion
(jammed finger)
• capsular distension in
rheumatoid arthritis
 Boutonnière Deformity -
Pathoanatomic Sequence

• Rupture of central slip

• causes the extrinsic extension mechanism from the EDC to be lost
• prevents extension at the PIP joint
• Attenuation of triangular ligament
• causes intrinsic muscles of the hand (lumbricals) to act as flexors at the PIP joint
• lumbricals also extend the DIP joint without an opposing or balancing force
• Palmar migration of collateral bands and lateral bands
• the lumbricals' pull becomes unopposed, pulling through the base of the distal
phalanx and volar to the PIP
• causes PIP flexion and DIP extension
• Bone deformity
• Injury involves all three phalanges
• the middle phalanx flexes on the proximal phalanx at the PIP joint
• the distal phalanx is hyperextended relative to the middle phalanx at the DIP joint
Boutonnière Deformity - Anatomy
• Muscle
• lumbrical muscles - originate
from the FDP and insert on the
lateral bands
• Ligament anatomy
• extensor hood and central slip
• the extrinsic extensor tendon
joins the extensor hood at the
MCP
• the central portion of the
extensor hood forms the
central slip
• the central slip inserts onto the
middle phalanx and acts to
extend the PIP joint
 Boutonnière Deformity - Anatomy
• lateral bands
• the lateral bands are formed
from the deep head of the
dorsal interossi combining with
the volar interossi
• the lateral bands insert onto the
base of the distal phalanx to
extend the DIP joint

• triangular ligament
• spans the two lateral bands,
preventing them from subluxing
volarly
• transverse retinacular ligament
• prevents dorsal subluxation of
the lateral bands
Boutonnière Deformity – On exam
• Deformity
• characterized by PIP flexion DIP extension
• Elson test
• most reliable way to diagnose a central slip injury before the deformity
is evident
• bend PIP 90° over edge of a table and extend middle phalanx against
resistance.
• in presence of central slip injury there will be
• weak PIP extension
• the DIP will go rigid
• in absence of central slip injury DIP remains floppy because the
extension force is now placed entirely on maintaining extension of the
PIP joint; the lateral bands are not activated

• Boyes test
• if an extensor mechanism injury has led to contracted lateral bands, as may
be seen in a subacute or chronic BD, the patient will be unable to actively
flex the DIP joint.
Boutonnière Deformity – Treatment

• Nonoperative
• splint PIP joint in full extension for 6 weeks
• indications
• acute closed injuries (< 4 weeks)
• technique
• encourage active DIP extension and flexion in splint to avoid
contraction of oblique retinacular ligament
• complete part-time splinting for an additional 4-6 weeks
• Operative
• primary central band repair
• indications
• acute displaced avulsion fx (proximal MP avulsion seen on x-ray)
• open wound that needs I&D
Boutonnière Deformity – Treatment

• lateral band relocation vs. terminal tendon tenotomy

vs. tendon reconstruction
• indications
• in chronic injuries after FROM is obtained with therapy or surgical release
• technique
• terminal tendon tenotomy (modified Fowler or Dolphin tenotomy)(never
central slip tenotomy)
• secondary tendon reconstruction (tendon graft, Littler, Matev)
• triangular ligament reconstruction
• PIP arthrodesis
• indications
• rheumatoid patients
• painful, stiff and arthritic PIP joint
Thank You
Chronic Boutonniere Deformity
• BDs can be categorized according to the Burton classification,
as follows :
• Burton stage I - BD with a supple and passively correctable joint
• Burton stage II - BD with a fixed contracture and contracted lateral
bands; PIP joint spaces are maintained
• Burton stage III - BD with a fixed deformity, contractures of lateral
bands, volar plate and collateral ligaments; the PIP joint suffers from
intra-articular fibrosis
• Burton stage IV - BD with a fixed deformity, contractures of lateral
bands, volar plate and collateral ligaments; the PIP joint suffers from
intra-articular fibrosis and arthritis as evident on radiography
• The Burton classification is based on the clinical examination
and plain radiographs. Ultimately, surgical management is
guided by the degree of deformity at the PIP joint, the
suppleness or correctability of the joints, and the presence of
arthritis at the PIP joint
Treatment plan in Boutonniere deformity

• Acute closed Boutonniere injuries: extension

splinting of PIP joint
• Acute open Boutonniere injuries: primary repair
( Doyle’s, Snow’s, Aiche’s methods)
• Chronic Boutonniere deformity: Stage 1 & 2-
therapy regimen of active assisted extension of the
PIP joint combined with passive flexion of the DIP
joint . Stage 3 – options include Tenotomy, Tendon
grafting, Tendon relocation
Burton & Melchior’s guidelines for Boutonniere
surgery

• Boutonniere reconstruction are most successful on supple joints.

If necessary, a joint release can be performed as a first stage.
• An Arthritic joint usually precludes soft tissue reconstruction. The
surgeon should consider either a PIP joint fusion or Arthroplasty
with extensor tendon reconstruction
• Boutonniere deformity rarely compromise PIP flexion & grip
strength. Do not trade extension at the PIP joint for a stiff finger
& a weak hand
• Goal of Boutonniere reconstruction is to rebalance the extensor
system by reducing extensor tone at the DIP joint and increasing
tone at the PIP joint
• Splinting is an important component of the postoperative care; it
may be necessary for several months