Swan Neck Deformity vs

Boutonniere Deformity
Team V : SD/AJ/MB/KY
Supervisor : dr. Henry Yurianto, Mphill, PhD, SpOT (K)
EXTENSOR
TENDON
ANATOMY

Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
 Swan Neck Deformity
• Described as a flexion posture of the distal
interphalangeal (DIP) joint and hyperextension posture
of the proximal interphalangeal (PIP) joint, at times
with flexion of the metacarpophalangeal (MCP) joint.
• It is caused by muscle imbalance and may be passively
correctable, depending on the fixation of the original
and secondary deformities. Although usually associated
with rheumatoid arthritis, swan neck deformity may
occur in patients with lax joints and in patients with
conditions such as Ehler-Danlos syndrome.
Van Der Giesen FJ, Van Lankveld WJ, Kremers-Selten C et al. Effectiveness of Two Finger Splints for Swan Neck Deformity in Patients with
Rheumatoid Arthritis. A Randomized, Crossover Trial. Arthritis & Rheum 2009;61:1025-1031
 Swan Neck Deformity

Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
 Swan Neck Deformity
• Cause: Volar plate rupture at the PIP with often
accompanying triangular ligament rupture.
• Pathology: Lateral bands drift dorsally and exacerbate the
hyperextension at the PIP joint. They become ineffective
in extension at the DIP joint and the unopposed action of
the profundus causes flexion at the DIP joint.
• Clinically: Causes “jamming dislocations immediately
noticeable, if not immobilized will become surgical finger.
• Treatment: involves SORL (spiral oblique retinacular
ligament) reconstruction.

Mackin EJ, Callahan AD, Skirven TM et al (editors). Rehabilitation of the Hand and Upper Extremity. 5th ed. Mosby: 2002;1573-76.
Mackin EJ, Callahan AD, Skirven TM et al (editors). Rehabilitation of the Hand and Upper Extremity. 5th ed. Mosby: 2002;1573-76.
 Swan Neck Deformity

Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
 Swan Neck Deformity

Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
Treatment Options for Swan Neck Deformity in
Fingers Type MP Joint PIP Joint DIP Joint
I   Splint Fusion
    Dermadesis  
    FDS sling  
Littler's ORL
     
reconstruction
II Intrinsic release As for type I Fusion
III As for type II As for type II Fusion
MP joint PIP joint
  reconstruction as  
manipulation
needed
    Skin release  
    Lateral band  
mobilization
    Check flexor tendons  
IV As for type III As for type III Fusion
    Arthroplasty  
    Fusion  
Thompson Jon C, Machado Carlos A.G, Craig John A. Arm in Netter’s Concise Orthopaedic Anatomy 2 nd edtion. p. 111-121
 Treatment – swan neck
Modalities
• Ice to decrease swelling and pain
• Contrast baths to decrease swelling
• Moist heat applied with finger positioned at end of
available range to increase range
• Laser to decrease pain
• Ultrasound in water to decrease joint tenderness
• Trancutaneous Nerve Stimulation (TNS) to decrease pain
• Wax followed by hand exercises

Mackin EJ, Callahan AD, Skirven TM et al (editors). Rehabilitation of the Hand and Upper Extremity. 5th ed. Mosby: 2002;1573-76.
 Treatment – swan neck
• PIP hyperextension and DIP flexion
• Lateral band displace dorsally
• Trauma and RA
• Goal of splinting is to prevent PIP
hyperextension and to promote DIP
extension
• Splint should have the PIP
In slight flexion (20 degrees)

Mackin EJ, Callahan AD, Skirven TM et al (editors). Rehabilitation of the Hand and Upper Extremity. 5th ed. Mosby: 2002;1573-76.
 Treatment – swan neck
• Watch out from allowing the PIP joint to go
into extension while fabricating the splint
• Make sure you eliminate the splint bulk to
allow function as much as possible

Mackin EJ, Callahan AD, Skirven TM et al (editors). Rehabilitation of the Hand and Upper Extremity. 5th ed. Mosby: 2002;1573-76.
 Boutonniere Deformity

Krueger Chad. Boutonniere deformity. Orthobullets. 2013

 Boutonniere Deformity

Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Krueger Chad. Boutonniere deformity. Orthobullets. 2013
Krueger Chad. Boutonniere deformity. Orthobullets. 2013
PATHOMECHANISM
 PATHOMECHANISM
RUPTURE OF CENTRAL
SLIP

ATTENUATION OF TRIANGULAR
LIGAMENT

PALMAR MIGRATION LATERAL BAND

BOUTONNIERE
DEFORMITY
 Boutonniere Deformity

Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
 Boutonniere Deformity

Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
 CLINICAL
• In anyone with tenderness or a cut over the
dorsum of the PIP joint, especially if they
cannot actively extend the IP joint with the
MCP joints and wrist flexed.
• Elson’s test → determine possible tear the
central slip before the deformity evident

Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
CLASSIFICATION
• Mild → PIP joint lag of 10⁰ - 15⁰ in extension
• Moderate → PIP joint lag of 30⁰ - 40⁰ in
extension
• Severe → PIP joint in fixed flexed postion with
joint involment

Krueger Chad. Boutonniere deformity. Orthobullets. 2013

 Treatment Options for Boutonniýre
Deformity of the Finger
Stage PIP Joint DIP Joint
I—Mild Dynamic splinting Extensor tenotomy
  Injection vs synovectomy  
II—Moderate Correct any wrist flexion first Extensor tenotomy
  Extensor reconstruction  
III—Severe Fusion (standard) Extensor tenotomy
  Arthroplasty  

Krueger Chad. Boutonniere deformity. Orthobullets. 2013

 Treatment – Boutonniere
• PIP flexion and DIP hyperextension
• Could result from (axial loading, tendon
laceration, burns, arthritis)
• The central extensor tendon (central slip)
is disrupted
• If not treated could lead
to contracture

Malkawi Somaya. Chapter 12. Splints for the fingers. 2013

 Treatment – Boutonniere
• Splinting: Maintain PIP ext while keeping
the DIP and MCP’s free for about 6-8
weeks
• Or include the DIP joint > MA
• If there is a contracture a serial splint or a
prefabricated splint might be used

Malkawi Somaya. Chapter 12. Splints for the fingers. 2013

 Boutonniere Deformity

Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
 Boutonniere Deformity

Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
 Boutonniere Deformity

Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Brown Richard A. Tendon repair. What’s new in hand surgery. Torrey Pines Orthopaedic Medical Group. 2011
Thank You