Arch Hand Microsurg.  2020 Dec;25(4):249-258. 10.12790/ahm.20.0056.

Boutonniere Deformity: A Review of Considerations before Treatment and Current Treatment Options

• Lee JK
• Kim C
• Han SH

• KMID: 2508937
• DOI: http://doi.org/10.12790/ahm.20.0056

Abstract

Central slip injury is a common occurrence in hand trauma. When the base of the middle phalanx, which is the contact part of the central tendon, is weakened or damaged, extension lag or restriction would be found in the proximal interphalangeal (PIP) joint and the distal interphalangeal joint becomes hyperextended, presenting buttonhole or boutonniere deformation. Buttonhole deformation has limited cases that a hand surgeon can experience, and there is still no clear guideline for treatment, so treatment tends to depend on the knowledge and experience of the treating doctor. In this review, the factors to be considered in determining the treatment of boutonniere deformity are discussed, and nonsurgical or surgical treatment is considered. Treatment of the PIP joint in boutonniere deformity is a difficult task. Understanding the cause of the deformity, the time point and the stage of deformity, the relationship to the biomechanical changes in adjacent joints, the patient’s functional limitations, and the condition of the joint will improve treatment decisions and outcomes. Based on these considerations, an appropriate treatment should be chosen among nonsurgical or surgical treatments. Various surgical options were introduced but none of method guarantee the optimal outcome. Sufficient understanding of deformity and sufficient consultation and cooperation with the patient regarding the treatment process, outcome, and rehabilitation are necessary.

Keyword

Boutonniere deformity; Central slip; Proximal interphalangeal joint; Surgical treatment

Figure

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  Fig. 1. Schematic drawing (A) and clinical photo (B) of the boutonniere deformity.

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  Fig. 2. Pseudo boutonniere deformity. (A) A 36-year-old male patients presented proximal interphalangeal joint flexion contracture on left 3rd and 4th finger 3 months after hyperextension injury in affected finger joint. The plain X-ray presented volar small bony fragments marked with red circles (B) and the finger distal interphalangeal joint flexion was intact (C).

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  Fig. 3. Boutonniere deformity in Dupuytren contracture disease. (A) A 65-year-old male patient presenting severe Dupuytren contracture on both hand. (B, C) The left 5th finger is also accompanied by boutonniere deformity. (D, E) With aggressive palmar fasciectomy and dorsal terminal tendon tenotomy, the deformity could be corrected.

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  Fig. 4. Lateral band dorsal translocation and sutured together. (A) A 61-year-old female patient presented over 90° extension lag in left 3rd finger. (B, C) With dorsal approach, the central tendon almost lost function and bilateral lateral bands were released and suture together at the center of middle phalanx. (D, E) The patient recovered 0° of extension in proximal interphalangeal joint but also presented distal interphalangeal joint flexion deficit.

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  Fig. 5. Central slip surgery. (A, B) A 35-year-old man with a 40° extensor lag of the proximal interphalangeal (PIP) joint and 20° hyperextension of distal interphalangeal joint after 10 months of initial tendon repair surgery at outer hospital in left 5th finger. (C) With a lazy S-shaped incision over the PIP joint, the elongated scar tissue is identified within the underlying joint capsule. (D) The bilateral sides of the central tendon are incised and released for advancement. (E) The proper length of scar tissue preventing the PIP full extension is resected, including the underlying joint capsule. (F) The volar plate and collateral ligament were release through exposed joint. (G, H) The proximal stump is advanced and the end repair between the distal stump containing the joint capsule using 4-strand core sutures at 0° PIP extension is performed. An additional Mitek Micro QuickAnchor (DePuy Mitek Inc., Raynham, MA, USA) is inserted and sutured to the proximal stump to enhance suture stability. (I, J) At the final clinical follow-up, the range of motion is recorded.

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  Fig. 6. Arthrodesis of proximal interphalangeal joint. (A, B) A-65-year old male patient with severe boutonniere deformity with fixed 100° proximal interphalangeal joint flexion contracture with coronal deformation in left 3rd finger. (C-F) The arthrodesis using transosseous two wirings was performed.

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