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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.

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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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