Boutonniere deformity refers to the funny zigzag position of the finger where the Proximal Interphalangeal (PIP) joint is in flexion and the Distal Interphalangeal (DIP) joint is in extension. It usually occurs from trauma or inflammatory conditions to the tendons traversing the finger.
In the acute traumatic situation (often the patient will tell us they just "jammed" their finger), the PIP joint may become forcibly flexed while in the extended position causing the central slip tendon to tear. Because there is a delicate balance between the tendons that flex and extend the joints, the DIP joint will eventually try to balance out and go the opposite direction into extension.
Any chronic inflammatory condition such as Rheumatoid Arthritis can also cause this problem. In these cases, the chronic inflammation causes deterioration to the tendons and tissues holding the tendons in their appropriate positions. These tendons then slide into non-anatomic positions causing the joints to deform.
Aside from the funny look of the finger, in the traumatic version, there can be pain and swelling at the PIP joint and weakness in trying to extend the PIP joint. It should be noted that the funny zigzag position may take weeks to develop, so the only real symptoms early on may just be pain and swelling at the PIP joint. Because of this, patients often show up late to the orthopedist's office, thinking they merely "jammed" the finger and hoping it would just get better on its own. The problem with this is that treatment of Boutonniere Deformities is best done as soon as the injury has occurred.
In the inflammatory version of this, the deformity can take several months to years to develop. There are often signs of inflammation in other fingers and joints.
Dr. Steven Lee will typically diagnose your Boutonniere Deformity clinically and using standard x-ray. However, there are times in which other radiologic studies or blood tests might be ordered to further figure out the cause of the problem or to rule out other disorders.
Unless there is an open wound associated with the Boutonniere Deformity, or if the joint is no longer passively mobile, the initial treatment for this is usually non-operative. Dr. Steven Lee will typically recommend the constant use of a splint to keep the PIP joint in extension, while also recommending flexion exercises for the DIP joint. Like the treatment of Mallet Fingers, the success of this non-operative treatment hinges on the patient wearing the splint 24/7 for every second of the day for up to 6 weeks. Momentarily removing the splint during this period causes resetting of the clock for another 6 weeks and significantly jeopardizes the success rates.
Following splinting, the splint is typically weaned off, and hand therapy is typically started to regain motion to the stiff finger. If there is an inflammatory component to the Boutonniere deformity, a consult from a Rheumatologist might be helpful.
In general, Dr. Steven Lee will only recommend surgery for Boutonniere deformity as a last resort. One exception to this is an open wound that has also lacerated the central slip tendon. In this case, it is recommended to wash out the wound to decrease the chance for infection, and to directly repair the tendon with sutures.
Surgery is also indicated if the patient shows up at such a late stage that the joint is permanently fixed in a flexed position and cannot be manually extended.
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The post-operative care depends on which type of treatment was utilized. The finger will typically be placed into a splint to hold the PIP joint in flexion for a variable amount of time. Hand therapy will then be an important part of the treatment process in order to regain range of motion.
It is important to note that even after successful treatment of a Boutonniere Deformity, whether nonoperative or surgical intervention, the PIP joint will often still have some flexion deformity to it.
Immediate Post-Operative Instructions
Please refer to the following pages for more information:
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City and Scarsdale.