Skip to content

Patients › Hand

Deformidad en forma de botón

PDF Evidence

Extensor central-slip injury at the middle finger joint; early splinting prevents the zigzag deformity, established cases need surgery.

Updated Sep 2026
Ilustración de un dedo con deformidad en forma de “boutonnière”: la articulación media está doblada y la punta del dedo inclinada hacia atrás.
Deformidad en forma de botón: la articulación del dedo medio permanece doblada y la punta del dedo se inclina hacia atrás. Kieran Hirpara 4.0

Esta página se tradujo automáticamente y todavía no la ha revisado un médico. La versión en inglés es la versión oficial.

Qué está sintiendo

La deformidad en forma de ojal altera la forma en que se dobla uno de sus dedos. La articulación media del dedo permanece doblada hacia abajo, mientras que la articulación distal apunta hacia arriba en lugar de doblarse. Esto ocurre cuando un pequeño tendón plano situado en el dorso del dedo (el tendón central) deja de funcionar. Ese tendón normalmente estira la articulación media; cuando se rompe, se estira o se desgasta, el dedo ya no puede enderezarse en ese punto.

El dedo puede resultar doloroso y dificultar enormemente el uso de la mano. Las tareas que requieren un dedo recto se vuelven complicadas: ponerse un guante, teclear, sostener un bolígrafo o recoger monedas pueden resultar incómodos o difíciles. Cualquier presión sobre la articulación doblada, como agarrar el volante o sostener una bolsa de la compra por el asa, puede intensificar el dolor. El descanso de la mano y mantener el dedo inmóvil suelen aliviar los síntomas.

Esta deformidad es frecuente en personas con artritis reumatoide; la inflamación continua dentro de la articulación media (sinovitis) va desgastando progresivamente ese tendón. Alrededor del 36 % de quienes padecen artritis reumatoide desarrollan una deformidad en forma de ojal, y aproximadamente la mitad presenta esta deformidad o una deformidad en forma de cuello de cisne. También puede aparecer tras una lesión, como un corte o un golpe fuerte en el dorso del dedo que dañe el tendón central.

La hinchazón y el dolor suelen seguir un patrón: al despertar, la articulación puede sentirse rígida y adolorida, pero se relaja un poco al empezar a moverla. Tras un día de uso intensivo de la mano, el dedo puede doler y parecer más doblado de lo habitual. También es común sentir un latido doloroso en la articulación durante la noche, especialmente si el dedo ha sido sometido a mucho esfuerzo.

Un dato importante: detectar esto a tiempo es fundamental. Si una lesión del tendón central se trata poco después de producirse, a menudo se puede evitar por completo el desarrollo de la deformidad.

¿Qué está ocurriendo realmente?

Imagínese el tendón situado en el dorso del dedo como una cuerda que recorre la parte superior y se divide en varias hebras cerca de la articulación media. Una de esas hebras, la porción central, se inserta en el hueso medio y estira dicha articulación. Las otras dos hebras se extienden a cada lado de esta. Normalmente, las tres trabajan conjuntamente, mantenidas en su lugar sobre la articulación por finas capas de tejido, algo similar a las cuerdas de sujeción que mantienen erguido un poste de tienda de campaña.

Cuando el dedo sufre una lesión, o cuando la artritis reumatoide deteriora el tendón desde el interior de la articulación, la porción central puede desprenderse o estirarse. Una vez que esto ocurre, las dos hebras laterales se deslizan por debajo de la articulación en lugar de permanecer por encima. A partir de ahí, tiran de la articulación media hacia abajo, provocando una posición flexionada en lugar de estirada. Por eso el dedo queda doblado en la articulación media y la punta apunta hacia arriba.

Para que esto suceda, es necesario que más de una estructura se dañe: la porción central del tendón, las capas de tejido que mantienen las hebras en su sitio y algunas de las fibras circundantes deben verse afectadas antes de que las hebras se desplacen realmente. Por este motivo, al principio el dedo puede presentar sensación de “clic” o bloqueo en la articulación media, antes de que se manifieste la deformidad completa.

Un último dato importante: una vez que la deformidad persiste durante mucho tiempo, la propia articulación se vuelve rígida y se adapta a esa posición flexionada. Incluso tras el tratamiento, puede quedar una pérdida de unos grados en la capacidad de estiramiento de la articulación media. Por eso, como se explicó anteriormente, el tratamiento temprano resulta fundamental.

Qué podemos hacer al respecto

El Dr. Kieran Hirpara, cirujano de extremidades superiores en el Mater Private Hospital Rockhampton, comienza con las opciones menos invasivas que se adapten a su condición. Por lo general, los pacientes son derivados a nuestra clínica por su médico de cabecera; si un fisioterapeuta le ha sugerido que nos consulte, igualmente necesitará una derivación de su médico de cabecera para poder acceder al reembolso de Medicare. En su primera visita, tomamos su historia clínica, examinamos su dedo y solicitamos estudios de imagen únicamente cuando esto modificará el plan de tratamiento. Un examen minucioso es lo que nos guía hacia las pruebas y el tratamiento adecuados.

En el caso de una deformidad de larga data, normalmente empezamos con el uso de férulas. Una vez que los yesos hayan cumplido su función, usted llevará una férula que mantiene el dedo en una posición que le permite seguir utilizando la mano. Debe usarla durante 3 meses. Este método resulta eficaz cuando los yesos han logrado reducir la extensión de la articulación media a menos de -20°, es decir, cuando el dedo puede enderezarse hasta 20 grados por debajo de la posición completamente recta; además, debe usar la férula de forma activa durante todo ese tiempo. Iniciar el tratamiento dentro de las 6 semanas posteriores a la lesión marca una gran diferencia en el grado de movilidad que se recuperará. En el caso de una lesión reciente del tendón central, mantenemos las articulaciones del dedo en extensión total (completamente rectas) durante cuatro semanas, y luego utilizamos una férula de resorte durante otras dos semanas. Durante la mayor parte de ese período, usted aún puede usar la mano para tareas ligeras.

Si el uso de férulas no logra enderezar suficientemente el dedo, la cirugía es el siguiente paso. La consideramos cuando el tendón ha sufrido daños que superan lo que una férula puede corregir, o cuando la deformidad se ha vuelto fija. La operación reconstruye el mecanismo tendinoso situado en la parte posterior del dedo para que este pueda volver a enderezar la articulación media. Cuando las fibras laterales del tendón están desgastadas o dañadas, podemos reconstruirlas empleando una tira de tendón extraída de su propia muñeca. Cada tipo de intervención cuenta con su propia página informativa; antes de tomar cualquier decisión, analizaremos cuál de ellas se adapta mejor a su dedo.

Qué esperar

El desenlace clínico depende en gran medida de la rapidez con que se trate el dedo. Si una lesión reciente del tendón extensor central se inmoviliza a tiempo, a menudo se puede evitar por completo la aparición de la deformidad. Si no se trata, la articulación media suele permanecer doblada y con el tiempo puede quedar fija en esa posición. Una vez que la deformidad ya está establecida, incluso un tratamiento adecuado puede dejar el dedo a unos pocos grados de no estar completamente recto.

En el caso de una deformidad ya consolidada, los primeros pasos son usar yesos para enderezar la articulación media, seguidos de 3 meses de uso de un splint mientras se sigue utilizando la mano. Este enfoque funciona cuando los yesos logran que la extensión de la articulación sea inferior a -20°, es decir, cuando el dedo se endereza hasta 20 grados por debajo de la posición completamente recta. Durante esos 3 meses es necesario mover activamente el dedo mientras se lleva el splint para recuperar la capacidad de flexión. Se trata de un proceso lento y requiere esfuerzo por parte del paciente: el splint solo será útil si realmente se ejercita el dedo mientras se usa.

Cuando el tratamiento con splint ya no aporta mejoras, la cirugía es el siguiente paso. Cuando los haces laterales del tendón están desgastados o dañados, se puede emplear una tira de tendón de la propia muñeca para reconstruirlos. En pacientes sometidos a esta operación por una deformidad de larga duración, los resultados fueron buenos o excelentes en 16 de 18 casos. Otra opción para deformidades crónicas es seccionar el tendón en la articulación distal; esto redujo notablemente la discapacidad y permitió recuperar la flexión en dicha articulación.

Algunas advertencias importantes: en las fases avanzadas de esta deformidad, las intervenciones quirúrgicas sobre los tejidos blandos por sí solas podrían no mantener la corrección de forma permanente. Además, si padece artritis reumatoide, las deformidades digitales pueden seguir apareciendo a medida que avanza la enfermedad; por ello, el plan de tratamiento tendrá en cuenta el grado de fijación de la articulación, su movilidad y el estado de su superficie articular. Nada de esto implica que la cirugía no sea útil; simplemente significa que el objetivo es lograr un dedo que funcione mejor, no garantizar que quede perfectamente recto.

Cuándo consultar a un especialista

Acuda a su médico de cabecera si un dedo ha comenzado a permanecer doblado en la articulación media y no se endereza, especialmente si padece artritis reumatoide. Solicite una evaluación por parte de un especialista si la articulación media le duele, se traba o hace un “chasquido”, o si le resulta cada vez más difícil usar ese dedo para las tareas cotidianas. Estos cambios suelen aparecer de forma gradual, por lo que es fácil atribuirlos al uso excesivo. El momento de actuar es crucial: iniciar el tratamiento dentro de las 6 semanas posteriores a la lesión influye enormemente en la recuperación del rango de movimiento; en cambio, cuando la deformidad ya existe desde hace tiempo, resulta mucho más difícil corregirla. Si observa que un dedo se dobla hacia abajo en la articulación media mientras la punta del dedo apunta hacia arriba, no espere a que mejore por sí solo.

En profundidad

Esta sección va más allá de lo necesario para tomar decisiones terapéuticas por su cuenta. La deformidad en “botón de abotonadura” merece una lectura adicional, ya que el tratamiento instintivo para un dedo doloroso, hinchado y doblado —es decir, dejarlo en reposo y sin moverlo— es precisamente lo que la evidencia científica no recomienda en absoluto.

Movilización temprana, no inmovilización prolongada

Una revisión sistemática de los tratamientos para lesiones del tendón central concluyó que la base de evidencia es limitada; además, el papel de las distintas estrategias tanto en lesiones abiertas como cerradas no está bien sustentado [1]. A pesar de dicha limitación, la evidencia proveniente de estudios individuales apoya de forma tentativa la movilización temprana y no respalda la inmovilización prolongada [1].

Esto merece ser expresado con claridad, pues va en contra de la reacción instintiva habitual. La diferencia radica en proteger el tendón central en proceso de curación, lo cual exige mantener la articulación media recta; en contraste, la inmovilización total del dedo provoca rigidez de la articulación distal y hace que todo el dedo se vuelva rígido. La férula tiene como finalidad mantener una sola articulación inmóvil mientras las demás siguen moviéndose.

¿Por qué la deformidad empeora en lugar de permanecer estable?

La deformidad en botón de chaqueta es progresiva; esto resulta poco común y merece ser comprendido. El tendón central se inserta en la base del hueso medio y estira la articulación media. Cuando este tendón falla, dicha articulación se flexiona, y las dos bandas laterales, que normalmente discurren por encima del eje articular, desplazanse por debajo de él.

Una vez debajo del eje articular, los mismos tendones que antes ayudaban a estirar la articulación media ahora la flexionan, al mismo tiempo que tiran de la punta del dedo hacia una hiperextensión. De este modo, la deformidad se auto-reforzar: cada intento de enderezar el dedo tensa aún más las estructuras que lo mantienen flexionado. Por eso, una lesión que parecía leve puede derivar en una deformidad fija semanas después; también explica por qué el período adecuado para aplicar férulas simples es muy temprano.

La deformidad que no es boutonnière

Un dedo puede adoptar la misma postura sin que exista lesión alguna en el tendón central; en ese caso, los tratamientos son completamente distintos. Las deformidades boutonnière y pseudoboutonnière difieren en cuanto a patoanatomía, diagnóstico y tratamiento [2]. La variante pseudoboutonnière se origina por una lesión de la placa volar en la articulación media; en este caso, la articulación distal del dedo conserva una flexión pasiva normal, en lugar de quedar en hiperextensión.

Para diferenciarlas en la práctica clínica, hay que observar la punta del dedo. En una boutonnière verdadera, la punta permanece en hiperextensión y resiste la flexión, especialmente cuando la articulación media está estirada; en una pseudoboutonnière, en cambio, la punta se flexiona con facilidad. Colocar una férula en una pseudoboutonnière como si fuera una boutonnière real implica tratar la articulación equivocada.

Pertenece a una familia de lesiones definidas según el lugar donde falla el tendón

La lesión en “boutonnière” se encuentra junto con la lesión en “mallet finger” y la lesión de la banda sagital como una de las tres lesiones del mecanismo extensor cerrado, clasificadas según la zona en la que se produce el fallo del mecanismo [3]. Las tres pueden manifestarse como un dedo hinchado que permanece en una posición anormal pocos días después de la lesión; además, cada una requiere una posición específica de la férula. Este es el motivo práctico por el cual vale la pena llegar a un diagnóstico preciso antes de someter al paciente a semanas de uso de férula.

Referencias

[1] Geoghegan L, Wormald JCR, Adami RZ, Rodrigues JN. Lesiones del tendón extensor de la porción central: revisión sistemática de los tratamientos. J Hand Surg Eur Vol. 2019;44(8):825-32. https://doi.org/10.1177/1753193419845311

[2] Hanson ZC, Thompson RG, Andrews JR, Lourie GM. Deformidades en muesca de botón versus pseudodeformidades en muesca de botón: patoanatomía, diagnóstico y tratamiento. J Hand Surg Am. 2023;48(5):489-97. https://doi.org/10.1016/j.jhsa.2022.10.019

[3] Lin JD, Strauch RJ. Lesiones cerradas del mecanismo extensor de partes blandas (dedo en martillo, deformidad en muesca de botón y lesión de la banda sagital). J Hand Surg Am. 2014;39(5):1005-11. https://doi.org/10.1016/j.jhsa.2013.11.018

Reviewed by Dr Kieran Hirpara · 10 June 2026.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management [1].
  • An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities [2].
  • Early treatment of central slip injuries can prevent the deformity [3].
  • The natural history of the boutonnière deformity in rheumatoid arthritis is outlined in the literature [5].
  • Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension [6].
  • For chronic boutonniere deformity, the patient must actively use the hand in a relative motion flexion orthosis for 3 months to recover flexion [6].
  • Serial casting for adequate extension followed by 3 months of relative motion flexion orthotic use should be attempted prior to surgical intervention for chronic boutonniere deformity [4].
  • Extensor tenotomy to correct a boutonnière deformity of long standing markedly lessened disability with restoration of flexion of the distal joint [10].
  • Transection of the terminal extensor tendon is a useful procedure for salvage of the boutonniere deformity [13].
  • The Y-shaped tendon graft can be a useful procedure for the correction of chronic boutonniere deformity [7].
  • In a patient series, the Y-shaped tendon graft provided good or excellent results in 16 of 18 patients for chronic boutonniere deformity [7].
  • The cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option with satisfactory results for chronic boutonniere deformity when the lateral bands are deficient or damaged [9].
  • Congenital boutonniere deformity is understood as various embryonic developmental failures [8].
  • Central slip reconstruction is a reliable surgical option for the congenital form of boutonniere deformity [8].

Anatomy & Pathophysiology

Extensor Mechanism Anatomy

  • The extensor mechanism of the finger at the level of the proximal interphalangeal (PIP) joint consists of both intrinsic and extrinsic contributions [19].
  • The extensor tendon entering the digit is the continuation of the extensor digitorum communis (EDC), with contributions from the extensor indicis proprius in the index finger and the extensor digiti quinti in the small finger [19].
  • In 30% of cases, the EDC has a separate insertion into the base of the proximal phalanx, but extension of the metacarpophalangeal (MP) joint most often occurs through the pull of the sagittal bands [19].
  • The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the MP joint [25].
  • At the level of the middle of the proximal phalanx, transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [25].
  • Oblique fibers (spiral fibers) from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx, extending the middle phalanx at the PIP joint [25].
  • The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [25].
  • The two conjoined lateral bands unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx to extend it [25].
  • The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [25].
  • The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [25].

Pathomechanics and Injury

  • A boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the PIP joint [15].
  • Damage to the central slip alone does not cause a boutonniere deformity [15].
  • A boutonniere deformity occurs only when the central slip, triangular ligament, and transverse and oblique fibers of the interosseous hood are all damaged [15].
  • Detachment of the central slip from the middle phalanx produces a decrease in extension of the PIP joint [15].
  • When the transverse and oblique fibers of the interosseous hood are divided in addition to the central slip, extension at the PIP joint is further decreased [15].
  • Extension of the PIP joint decreases as structures are progressively damaged [40].
  • Injury to the extensor mechanism, specifically the central slip, can lead to snapping or catching at the PIP joint [39].
  • In irreducible volar dislocations of the PIP joint caused by interposition of the intact central slip, the extensor mechanism is displaced rather than disrupted [47].
  • Long-standing complex pathophysiological changes in boutonniere deformity make full correction impossible, resulting in an inevitable few degrees of PIP joint extension deficit [46].

Classification

  • The boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the PIP joint [15].
  • Combined injury of the central slip, triangular ligament, and transverse and oblique fibers of the interosseous hood causes a boutonniere deformity [15].
  • Anterior dislocation of the proximal interphalangeal joint is associated with ruptures of the central slip of the extensor mechanism [18].
  • Anterior dislocation of the proximal interphalangeal joint results in boutonnière deformity unless repaired [18].
  • The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13% [11].

Clinical Presentation

  • A swan-neck or boutonniere deformity occurs in approximately half of patients with rheumatoid arthritis [16].
  • The incidence of uncorrectable swan-neck and boutonniere deformities is estimated to be between 8% and 16% during the first 2 years after the onset of systemic disease [16].
  • The prevalence of finger deformities in patients with established rheumatoid arthritis is approximately 36% for boutonniere deformities [16].
  • The cause of boutonniere deformity in rheumatoid arthritis is chronic synovitis of the proximal interphalangeal joint [16].
  • Boutonniere deformities can be painful and can impair finger and hand function significantly [16].
  • A boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the proximal interphalangeal joint [15].
  • Detachment of the central slip from the middle phalanx produces a decrease in extension of the proximal interphalangeal joint [15].
  • Division of the central slip leads to loss of extension at the proximal interphalangeal joint [15].

Investigations

  • A careful physical examination is essential to direct care and future testing if indicated [22].
  • Diagnostic tests such as imaging and serum laboratory studies are useful in the determination of pathology but can be expensive, time consuming, and often nonspecific [22].
  • The extensor mechanism of the finger at the level of the PIP joint consists of both intrinsic and extrinsic contributions [19].
  • The extensor tendon that enters the digit is the continuation of the extensor digitorum communis (EDC) and in the index and small fingers the extensor indicis proprius and extensor digiti quinti, respectively [19].
  • Thirty percent of the time the EDC has a separate insertion into the base of the proximal phalanx [19].
  • Extension of the metacarpophalangeal (MP) joint most of the time occurs through the pull of the sagittal bands [19].
  • A finite element model was developed and validated that successfully replicated the behavior of the digit under specific scenarios, including the extension of the DIP joint during Elson's test observed in cadaveric studies [12].
  • In a cadaver model, detachment of the central slip from the middle phalanx produced a decrease in extension of the PIP joint [15].
  • In a cadaver model, when the transverse and oblique fibers of the interosseous hood were also divided, extension at the PIP joint was further decreased [15].
  • In a cadaver model, a boutonniere deformity occurred only when the central slip, triangular ligament, and transverse and oblique fibers of the interosseous hood were all damaged [15].

Non-Operative

  • Chronic boutonniere deformity should be treated with serial casting for adequate extension followed by 3 months of relative motion flexion (RMF) orthotic use prior to surgical intervention [4].
  • Chronic boutonniere deformity responds to relative motion flexion splinting if serial casting places the proximal interphalangeal joint in less than -20° extension and the patient actively uses a relative motion flexion orthosis for 3 months [6].
  • The use of relative motion flexion orthoses (RMFO) is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity [36].
  • Improvement in digit range of motion is associated with the initiation of treatment within 6 weeks [21].
  • Improvement in digit range of motion is not associated with any particular type or length of conservative treatment [21].
  • Conservative treatment for central slip injuries involves immobilization of the proximal interphalangeal joint, distal interphalangeal joint, and metacarpophalangeal joint in full extension for four weeks followed by a Capener spring splint for two further weeks [45].
  • In a review of 115 central slip injuries, 24 uncomplicated closed or compound injuries treated conservatively resulted in 17 patients (71%) achieving an outcome of less than a 20° extension deficit at the PIPJ and more than 80% return of PIPJ flexion [45].
  • Patients treated within six weeks of injury had better outcomes in conservative management of central slip injuries [45].

Operative

  • A simple method of repair is described for the correction of the boutonnière deformity in rheumatoid arthritis [5].
  • The Y-shaped tendon graft is a useful procedure for the correction of chronic boutonniere deformity [7].
  • The cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option for chronic boutonniere deformity when the lateral bands are deficient or damaged [9].
  • The cross-lateral band reconstruction technique using palmaris longus autograft yields satisfactory results in chronic boutonniere deformity [9].

Complications

  • The prevalence of finger deformities in patients with established rheumatoid arthritis is approximately 14% for swan-neck deformities [16].
  • Swan-neck deformity may be caused by synovitis of the metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joints [16].
  • In the later stages of both swan-neck and boutonniere deformities, soft-tissue procedures alone may not result in lasting operative correction [16].

Recovery

  • Chronic boutonniere deformity should be treated with serial casting for adequate extension followed by 3 months of relative motion flexion orthotic use prior to surgical intervention [4].
  • Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion [6].
  • The Y-shaped tendon graft provided good or excellent results in 16 of 18 patients for the correction of chronic boutonniere deformity [7].
  • The incidence of uncorrectable swan-neck and boutonniere deformities is estimated to be between 8% and 16% during the first 2 years after the onset of systemic disease in rheumatoid arthritis [16].
  • The prevalence of finger deformities in patients with established rheumatoid arthritis is approximately 14% for swan-neck deformities and 36% for boutonniere deformities [16].
  • Treatment decisions for boutonniere deformity in rheumatoid arthritis are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface [20].

Key Evidence

  • [L5] Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management. [1] (10.1016/j.jhsa.2022.10.019)
  • [L5] An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities. [2] (10.5435/jaaos-d-14-00272)
  • [L5] The paper outlines the anatomy, pathoanatomy, and treatment concepts for boutonniere deformity, emphasizing that early treatment of central slip injuries can prevent the deformity. [3] (10.1016/s0749-0712(21)00060-3)
  • [L4] Similar results occurred for chronic boutonniere deformity using serial casting for adequate extension followed by 3 months of RMF orthotic use, which should be attempted prior to surgical intervention. [4] (10.1016/j.jht.2023.02.005)
  • [L4] The natural history of the boutonnière deformity in rheumatoid arthritis is outlined, and a simple method of repair is described. [5] (10.2106/00004623-196951070-00009)
  • [L4] Chronic boutonniere deformity will respond to relative motion flexion splinting if serial casting can place the proximal interphalangeal joint in less than -20° extension, and the patient actively uses the hand in a relative motion flexion orthosis for 3 months, recovering flexion. [6] (10.1097/sap.0000000000002307)
  • [L4] The Y-shaped tendon graft can be a useful procedure for the correction of chronic boutonniere deformity; in our patient series, this provided good or excellent results in 16 of 18 patients. [7] (10.1016/j.jhsa.2021.01.003)
  • [Case_report] The case extends understanding of congenital boutonniere deformity as various embryonic developmental failures and suggests a reliable surgical option involving central slip reconstruction. [8] (10.1016/j.jhsa.2014.05.030)
  • [L4] In chronic boutonniere deformity, when the lateral bands are deficient or damaged, the cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option with satisfactory results. [9] (10.1016/j.jhsa.2017.04.010)
  • [L3] The prevalence of boutonnière deformity without rheumatoid arthritis or trauma is approximately 13%. [11] (10.1177/1753193417704610)
  • [L5] The study developed and validated a finite element model that successfully replicated the behavior of the digit under specific scenarios, including the extension of the DIP joint during Elson's test observed in cadaveric studies. [12] (10.1186/s13018-025-06329-3)
  • [L4] Transection of the terminal extensor tendon is a useful procedure for salvage of the boutonniere deformity. [13] (10.1016/s0749-0712(21)00065-2)
  • [L5] [15] (10.1016/j.jhsa.2017.07.011)
  • [L5] [16] (10.5435/00124635-199903000-00002)
  • [Paper] [19] (10.1016/j.hcl.2012.05.044)
  • [L5] Treatment decisions are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface. [20] (10.1016/j.jhsa.2011.05.029)
  • [L3] Improvement in digit ROM was associated with initiation of treatment within 6 weeks, but not with any particular type or length of conservative treatment. [21] (10.1016/j.jht.2025.02.013)
  • [L4] The use of RMFO is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity. [36] (10.1016/j.jhsa.2022.08.007)
  • [Case_report] Hand surgeons should be aware that injury to the extensor mechanism and specifically the central slip can lead to snapping or catching at the PIP joint in the finger. [39] (10.1177/15589447221081876)
  • [Paper] Extension of the PIP joint decreases as these structures are progressively damaged. [40] (10.1016/s0363-5023(12)60014-8)
  • [L4] [45] (10.1177/1758998318822663)
  • [L4] Due to long-standing complex pathophysiological changes, full correction may not be possible, and a few degrees of PIP joint extension deficit is inevitable. [46] (10.1016/j.otsr.2021.102971)
  • [L4] The prognosis is far better after irreducible than after reducible volar dislocations because the extensor mechanism is displaced, not disrupted. [47] (10.2106/00004623-197860010-00023)

References

[1] Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.10.019

[2] Posttraumatic Boutonnière and Swan Neck Deformities. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00272

[3] BOUTONNIERE DEFORMITY. Hand Clinics. 1995. DOI: 10.1016/s0749-0712(21)00060-3

[4] The relative motion concept in acute and chronic boutonniere deformity: Invited commentary. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.02.005

[5] Correction of the Rheumatoid Boutonnière Deformity. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00009

[6] A Paradigm Shift in Managing Acute and Chronic Boutonniere Deformity. Annals of Plastic Surgery. 2020. DOI: 10.1097/sap.0000000000002307

[7] Y-Shaped Tendon Graft—A Technique in the Reconstruction of Posttraumatic Chronic Boutonniere Deformity. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.01.003

[8] Restoration of the Central Slip in Congenital Form of Boutonniere Deformity: Case Report. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.030

[9] Chronic Boutonniere Deformity: Cross-Lateral Band Technique Using Palmaris Longus Autograft. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.04.010

[10] Extensor Tenotomy for Chronic Boutonniere Deformity of the Finger: REPORT OF TWO CASES.. The Journal of Bone and Joint Surgery. American Volume. 1965.

[11] Thumb boutonnière deformity without rheumatoid arthritis or trauma. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417704610

[12] Assessment of the ligamentous stress distribution in the pathomechanics of the boutonniere deformity through a computational 3D model. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06329-3

[13] TREATMENT OF THE CHRONIC BOUTONNIERE DEFORMITY BY EXTENSOR TENOTOMY. Hand Clinics. 1995. DOI: 10.1016/s0749-0712(21)00065-2

[15] Biomechanics of the Acute Boutonniere Deformity. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.07.011

[16] Operative Correction of Swan-Neck and Boutonniere Deformities in the Rheumatoid Hand. Journal of the American Academy of Orthopaedic Surgeons. 1999. DOI: 10.5435/00124635-199903000-00002

[18] Anterior dislocation of the proximal interphalangeal joint. A cause of rupture of the central slip of the extensor mechanism.. The Journal of bone and joint surgery. American volume. 1970.

[19] Boutonnière and Pulley Rupture in Elite Athletes. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.05.044

[20] Treatment of Boutonniere Finger Deformity in Rheumatoid Arthritis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.029

[21] Nonoperative treatment of the Boutonniere deformity: Is there a difference in outcomes?. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2025.02.013

[22] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[25] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[36] The Use of Relative Motion Flexion Orthoses for Chronic Boutonniere Deformity. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2022.08.007

[39] Longitudinal Tear of the Central Slip Causing Painful and Unusual Snapping of the Finger: A Case Report. HAND. 2022. DOI: 10.1177/15589447221081876

[40] Biomechanics of the Acute Boutonniere Deformity. The Journal of Hand Surgery. 2012. DOI: 10.1016/s0363-5023(12)60014-8

[45] Therapeutic management of closed central slip injuries: Outcome of a service evaluation. Hand Therapy. 2019. DOI: 10.1177/1758998318822663

[46] RETRACTED: Flexor Digitorum Superficialis tendon transfer for a long-standing boutonniere deformity finger- a retrospective study of 11 cases. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102971

[47] Irreducible volar dislocation of the proximal interphalangeal joint of a finger caused by interposition of the intact central slip. The Journal of Bone & Joint Surgery. 1978. DOI: 10.2106/00004623-197860010-00023

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.