Boutonniere Deformity – Causes, Symptoms & Treatment
Boutonniere deformity is a finger condition where the middle joint is bent and the end joint is hyperextended. It is commonly caused by rheumatoid arthritis or traumatic tendon injuries.
Things worth knowing about "Boutonniere deformity"
Boutonniere deformity is a finger condition where the middle joint is bent and the end joint is hyperextended. It is commonly caused by rheumatoid arthritis or traumatic tendon injuries.
What is Boutonniere Deformity?
Boutonniere deformity is a characteristic finger deformity affecting the proximal interphalangeal (PIP) joint – the middle knuckle – and the distal interphalangeal (DIP) joint – the fingertip joint. In this condition, the PIP joint is permanently flexed (bent), while the DIP joint is hyperextended (bent backward). The name derives from the French word for buttonhole (boutonniere), as the central slip of the extensor tendon tears apart and the joint head protrudes through the gap like a finger through a buttonhole.
Causes
Boutonniere deformity can develop from several causes:
- Rheumatoid arthritis: The most common cause. Chronic inflammation damages the extensor tendon mechanism at the PIP joint.
- Traumatic injuries: A rupture or laceration of the central slip of the extensor tendon due to cuts, avulsion injuries, or blunt force.
- Systemic inflammatory conditions: Other inflammatory joint diseases such as psoriatic arthritis or systemic lupus erythematosus (SLE) can also cause boutonniere deformity.
- Infections: Severe finger infections may damage the extensor tendon apparatus.
Anatomical Background
The extensor tendon mechanism of the finger is a complex system of tendons and ligaments. The central slip of the extensor tendon inserts at the middle phalanx and extends the PIP joint. The lateral bands maintain the DIP joint in its normal position. When the central slip is torn or damaged, the lateral bands shift downward (palmarly), causing flexion of the PIP joint and simultaneous hyperextension of the DIP joint – the classic appearance of boutonniere deformity.
Symptoms
Typical signs of boutonniere deformity include:
- Persistent flexion of the middle finger joint (PIP), which can barely or not at all be corrected passively
- Hyperextension of the end joint (DIP)
- Pain and swelling at the PIP joint, especially in early stages
- Reduced grip function of the hand
- Progressive stiffening of the affected joints over time
Diagnosis
Diagnosis is usually made through a clinical examination by a physician, assessing joint position, active and passive range of motion. Additional investigations may include:
- X-ray: To rule out bony changes or avulsion fractures
- Ultrasound or MRI: For assessment of tendons and soft tissue structures, especially in uncertain cases
- Laboratory tests: If an underlying rheumatic disease is suspected (e.g., rheumatoid factor, anti-CCP antibodies)
Treatment
Conservative Treatment
In early stages or following acute injuries, conservative management can be effective:
- Splinting: The PIP joint is immobilized in extension (using a Stack or Boutonniere splint) to allow healing of the central slip. Treatment typically lasts 6–8 weeks.
- Physical therapy: Targeted exercises to restore mobility and strength
- Anti-inflammatory medications: Systemic therapy for underlying rheumatic disease (e.g., DMARDs)
Surgical Treatment
In advanced or chronic deformities that cannot be managed conservatively, surgical options include:
- Tendon reconstruction: Repair or reconstruction of the central slip by suturing or grafting
- Arthrodesis (joint fusion): For severe joint destruction, as a final option to reduce pain and provide stability
- Joint replacement: In selected cases, implantation of a finger joint prosthesis
Prognosis
The prognosis depends largely on the stage of deformity and the underlying condition. Boutonniere deformities identified and treated early – especially following traumatic injury – have a good chance of full recovery. Chronic cases associated with rheumatic diseases require ongoing treatment to preserve hand function for as long as possible.
References
- Skirven TM et al. Rehabilitation of the Hand and Upper Extremity. 7th edition. Elsevier, Philadelphia 2021.
- Wolfe SW et al. Green's Operative Hand Surgery. 7th edition. Elsevier, Philadelphia 2017.
- Smolen JS et al. EULAR recommendations for the management of rheumatoid arthritis. Annals of the Rheumatic Diseases, 2020.
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