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Boutonnière Deformity : Clinical essentials

Introduction
Extensor injuries of the hand are common in young, otherwise healthy males. Various injury mechanisms include hyperflexion, direct blunt trauma and penetrating trauma. When left untreated, disruption of the extensor mechanism over zone III and detachment of the central slip leads to a Boutonniere deformity. This deformity is characterised by flexion of the proximal interphalangeal joint (PIP) and hyperextension of the distal interphalangeal joint (DIP) due to the volar subluxation of the lateral bands.

Definition
A Boutonniere deformity is a deformity of the fingers in which the proximal interphalangeal joint (PIP) is flexed and the distal interphalangeal joint (DIP) is hyperextended. It is an extensor tendon injury over zone III. It is also referred to as a "buttonhole deformity."

Clinically relevant anatomy
The Extensor Digitorum Communis(EDC) tendon at each finger splits into three bands or slips namely the central tendon/slip, which inserts on the base of the middle phalanx, and two lateral bands/slips, which rejoin as the terminal tendon/slip to insert into the base of the distal phalanx. In order to produce active interphalangeal extension, the EDC muscle requires the assistance of two intrinsic muscle groups, the interossei and the lumbricals, that also have attachments to the extensor hood and the lateral bands/slips. The EDC tendon and all its complicated active and passive interconnections at and distal to the metacarpophalangeal joint are known together as the extensor mechanism. The foundation of the extensor mechanism is formed by the tendons of the EDC muscle (with extensor indicis and extensor digiti minimi) and the extensor hood, the central tendon/slip, and the lateral bands/slips that merge into the terminal tendon/slip. The triangular ligament helps stabilize the bands on the dorsum of the finger. The triangular ligament provides stability to the lateral bands preventing palmar subluxation during flexion of the proximal interphalangeal joint.

Symptoms
Signs of boutonnière deformity can develop immediately following an injury to the finger or may develop a week to 3 weeks later.

The finger at the middle joint cannot be straightened and the fingertip cannot be bent.
Swelling and pain occur and continue on the top of the middle joint of the finger.

Treatment
Boutonnière deformity must be treated early to help you retain the full range of motion in the finger.

Nonsurgical Options
Nonsurgical treatment is usually preferred, and may include:
Splints: A splint will be applied to the finger at the middle joint to straighten it. This keeps the ends of the tendon from separating as it heals. It also allows the end joint of the finger to bend. It is important to wear the splint continuously for the recommended length of time usually 6 weeks for a young patient and 3 weeks for an elderly patient. Following this period of immobilization, you may still have to wear the splint at night.

Exercises: Your physician may recommend stretching exercises to improve the strength and flexibility in the fingers.
Protection: If you participate in sports, you may have to wear protective splinting or taping for several weeks after the splint is removed.
People with boutonnière deformity caused by arthritis may be treated with oral medications or corticosteroid injections, as well as splinting.

Surgical Options
While nonsurgical treatment of boutonnière deformity is preferred, surgery is an option in certain cases, such as when:

The deformity results from rheumatoid arthritis.
The tendon is severed.
A large bone fragment is displaced from its normal position.
The condition does not improve with splinting.
Surgery can reduce pain and improve functioning, but it may not be able to fully correct the condition and make the finger look normal. If the boutonniere deformity remains untreated for more than 3 weeks, it becomes much more difficult to treat.

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