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Boutonniere Deformity

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Topic updated on 02/24/13 7:06am
Introduction
  • A Zone III extensor tendon injury characterized by  
    • PIP flexion
    • DIP extension
  • Mechanism
    • caused by rupture of the central slip over PIP joint from
      • laceration
      • traumatic avulsion (jammed finger)
      • capsular distension in rheumatoid arthritis
  • Pathoanatomy
    • pathoanatomic sequence includes
      • rupture of central slip 
        • causes the extrinsic extension mechanism from the EDC to be lost
        • prevents extension at the PIP joint
      • attenuation of triangular ligament 
        • causes intrinsic muscles of the hand (lumbricals) to act as flexors at the PIP joint
        • lumbricals also extend the DIP joint without an opposing or balancing force
      • palmar migration of collateral bands and lateral bands
        • the lumbricals' pull becomes unopposed, pulling through the base of the distal phalanx and volar to the PIP
        • causes PIP flexion and DIP extension
    • bone deformity
      • injury involves all three phalanx
      • the middle phalanx flexes on the proximal phalanx at the PIP joint
      • the distal phalanx is hyperextended relative to the middle phalanx at the DIP joint
  • Associated conditions
    • rheumatoid arthritis
    • pseudo-boutonniere
      • refers to PIP joint flexion contracture in the absence of DIP extension
Anatomy
  • Muscle
    • lumbrical muscles
      • originate from the FDP and insert on the lateral bands
  • Ligament anatomy
    • extensor hood and central slip
      • the extrinsic extensor tendon joins the extensor hood at the MCP
      • the central portion of the extensor hood forms the central slip
      • the central slip inserts onto the middle phalanx and acts to extend the PIP joint
    • lateral bands
      • the lateral bands are formed from the deep head of the dorsal interossi combining with the volar interossi
      • the lateral bands insert onto the base of the distal phalanx to extend the DIP joint
    •  triangular ligament
      • spans the two lateral bands, preventing them from subluxing volarly
    • transverse retinacular ligament
      • prevents dorsal subluxation of the lateral bands
  • Blood supply
    • interosseous muscles
      • receive blood from vessels formed by a combination of the deep palmer arch and the ulnar artery
Presentation
  • Physical exam 
    • Elson test  
      • is the most reliable way to diagnose a central slip injury before the deformity is evident
      • bend PIP 90° over edge of a table and extend middle phalanx against resistance.
        • in presence of central slip injury there will be
          • weak PIP extension
          • the DIP will go rigid
        • in absence of central slip injury DIP remains floppy because the extension force is now placed entirely on maintaining extension of the PIP joint; the lateral bands are not activated
Imaging
  • Radiographs
    • recommended view
      • radiographs are not required in evaluation and treatment of Boutonniere deformity
Treatment
  • Nonoperative
    • splint PIP joint in full extension for 6 weeks
      • indications
        • acute closed injuries (< 4 weeks)
      • technique
        • encourage active DIP extension and flexion in splint to avoid contraction of oblique retinacular ligament
        • complete part-time splinting for an additional 4-6 weeks
  • Operative
    • primary central band repair
      • indications
        • acute displaced avulsion fx (proximal MP avulsion seen on x-ray)
        • open wound that needs I&D
    •  lateral band relocation vs. terminal tendon tenotomy vs. tendon reconstruction 
      • indications
        • in chronic injuries after FROM is obtained with therapy or surgical release
      • technique
        • terminal tendon tenotomy (Fowler)(never central slip tenotomy)
        • secondary tendon reconstruction (tendon graft, Littler, Matev)
        • triangular ligament reconstruction
    • PIP arthrodesis
      • indications
        • rheumatoid patients
        • painful, stiff and arthritic PIP joint

 

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Qbank (2 Questions)

TAG
(OBQ09.80) Chronic injury to what anatomic structure can lead to a boutonneire deformity of the finger? Topic Review Topic

1. terminal extensor tendon
2. sagittal band
3. volar plate
4. flexor digitorum profundis tendon insertion
5. central slip of the extensor tendon

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TAG
(OBQ04.71) A 54-year-old female presents with a hand deformity. A surgical procedure is being considered that relocates the lateral bands dorsally to counteract the pathophysiology of the deformity. Which of the following deformities does this patient most likely have? Topic Review Topic

1. Boutonneire finger deformity
2. Lumbrical plus finger deformity
3. Mallet finger deformity
4. Jersey finger deformity
5. Swan neck finger defomity

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Videos

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Video showing Elson's test for Boutonniere deformity
2/23/2013
600 views
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Educational video describing the Boutonniere deformity of the fingers, including...
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