Boutonnière Deformity

Flexion deformity of the PIP joint and extension of the DIP joint.

It is due to interruption or stretching of the central slip of the extensor tendon where it inserts into the base of
middle phalanx. The lateral slips separate and the head of the proximal phalanx thrusts through the gap like a
buttonhole. Therefore it is called “boutonniere” deformity or “le buttonhole”.

Causes:

 Direct trauma
 Rheumatoid disease

Clinical features:

 Initially the deformity is slight and passively correctable

 Later on the soft tissue contract, resulting in fixed flexion
of the proximal and hyperextension of the DIP joint

Treatment:

 In early post-traumatic case

o Splint the PIP joint in full extension for 6 weeks
o DIP joint must be moved passively to prevent lateral bands from sticking
o Open injuries of the central slip should be repaired
o The joint protected by K-wire for 3 weeks
 Longstanding fixed deformities are extremely difficult to correct and may be better left alone

Swan-Neck Deformity

Reversed Boutonniere deformity

PIP joint is hyperextended and DIP joint flexed.

Pathology:

Imbalance of extensor versus flexor action at the PIP joint

Laxity of palmar plate

Treatment:

 If the deformity corrects passively

o Simple figure-of-eight ring splint to maintain PIP joint in a few degrees of flexion
o If it works but can’t be tolerated, then Tenodesis of PIP joint
 If deformity is fixed
o Gentle no response  Lateral band release from central slip
 If function is severely impaired and doesn’t respond to treatment
o Arthrodesis in a more acceptable position