ਬੂਟਨੀਅਰ ਡਿਫਾਰਮਿਟੀ

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 [2].
• An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities [4].
• The paper outlines the anatomy, pathoanatomy, and treatment concepts for boutonniere deformity, emphasizing that early treatment of central slip injuries can prevent the deformity [7].
• The natural history of the boutonnière deformity in rheumatoid arthritis is outlined, and a simple method of repair is described [3].
• The case extends understanding of congenital boutonniere deformity as various embryonic developmental failures and suggests a reliable surgical option involving central slip reconstruction [8].

Anatomy & Pathophysiology¶

• A finite element model successfully replicated the behavior of the digit under specific scenarios, including the extension of the DIP joint during Elson's test [12].
• Injury to the extensor mechanism, specifically the central slip, can lead to snapping or catching at the PIP joint [24].
• Progressive damage to structures involved in Boutonniere deformity results in decreased extension of the PIP joint [25].
• A release procedure based on precise anatomy redistributes forces acting on the interphalangeal joints to restore full extension and flexion [26].
• Asymmetrical position of the distal phalanges during extension suggests a central slip lesion, while symmetrical position indicates the lesion is unlikely [28].
• Irreducible volar dislocation of the PIP joint can be caused by interposition of the intact central slip [31].
• In irreducible volar dislocations, the prognosis is better than in reducible dislocations because the extensor mechanism is displaced rather than disrupted [31].
• Congenital hypoplasia of the extensor tendon central slip can be treated successfully with a static hand brace to keep the PIP joint in extension [35].

Classification¶

• The boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the proximal interphalangeal (PIP) joint [15].
• Anterior dislocation of the PIP joint is associated with ruptures of the central slip of the extensor mechanism and results in boutonniere deformity unless repaired [16].
• Early treatment of central slip injuries can prevent the development of boutonniere deformity [7].
• The natural history of boutonniere deformity in rheumatoid arthritis is distinct from other etiologies [3].
• Congenital boutonniere deformity results from various embryonic developmental failures [8].
• Boutonniere deformity can occur in the thumb without rheumatoid arthritis or trauma [11].
• The prevalence of boutonniere deformity without rheumatoid arthritis or trauma is approximately 13% [11].

Clinical Presentation¶

• Boutonniere deformities are closed soft tissue injuries of the extensor mechanism in zones I, III, and V [14].
• Elson's test involves extension of the distal interphalangeal (DIP) joint [12].

Investigations¶

• This article summarizes current concepts relating to the presentation and treatment of closed soft tissue injuries of the extensor mechanism in zones I, III, and V, commonly known as mallet finger, boutonniere deformities, and sagittal band injuries [14].
• The article discusses injuries to the central slip (boutonniere) and annular pulleys in elite athletes, emphasizing the importance of anatomic knowledge, accurate diagnosis, and balancing early return to play with long-term risks [18].
• The boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the PIP joint [15].
• Anterior dislocation of the proximal interphalangeal joint is associated with ruptures of the central slip of the extensor mechanism and results in boutonnière deformity unless repaired [16].
• Treating swan neck and boutonniere deformities of the PIP joint is a difficult challenge that requires understanding the cause, biomechanical changes, and articular status [17].
• 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].

Treatment¶

Non-Operative Management¶

• Serial casting for adequate extension followed by 3 months of relative motion flexion (RMF) orthotic use should be attempted prior to surgical intervention for chronic boutonniere deformity [1].
• 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 the hand in a relative motion flexion orthosis for 3 months to recover flexion [5].
• The use of relative motion flexion orthoses (RMFO) is effective in increasing active distal interphalangeal joint flexion and improving proximal interphalangeal joint extension in patients with Burton stage 1 chronic boutonniere deformity [23].
• Improvement in digit range of motion is associated with the initiation of nonoperative treatment within 6 weeks [20].
• The type or length of conservative treatment is not associated with differences in outcomes for nonoperative treatment of boutonniere deformity [20].

Operative Management¶

• The natural history of boutonniere deformity in rheumatoid arthritis has been outlined, and a simple method of repair is described [3].
• The Y-shaped tendon graft is a useful procedure for the correction of chronic boutonniere deformity, providing good or excellent results in 16 of 18 patients in a reported series [6].
• When lateral bands are deficient or damaged in chronic boutonniere deformity, cross-lateral band reconstruction using palmaris longus autograft is a treatment option with satisfactory results [9].
• Extensor tenotomy to correct a long-standing boutonniere deformity markedly lessens disability with restoration of flexion of the distal joint [10].
• Transection of the terminal extensor tendon is a useful salvage procedure for boutonniere deformity [13].
• Central slip reconstruction is a reliable surgical option for congenital boutonniere deformity [8].

Complications¶

• Chronic boutonniere deformity may result from untreated or inadequately treated central slip injuries [7].
• Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical to avoid inappropriate clinical management [2].
• The natural history of boutonnière deformity in rheumatoid arthritis involves progressive deformity requiring repair [3].
• Boutonnière deformity can occur in the thumb without underlying rheumatoid arthritis or trauma, with a prevalence of approximately 13% in such cases [11].
• Chronic boutonniere deformity can lead to marked disability and loss of flexion of the distal joint if left uncorrected [10].

Recovery¶

• The Y-shaped tendon graft is a useful procedure for correcting chronic boutonniere deformity, providing good or excellent results in 16 of 18 patients in a reported series [6].
• Extensor tenotomy can correct long-standing boutonniere deformity by markedly lessening disability and restoring flexion of the distal joint [10].

Key Evidence¶

• [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. [1] (10.1016/j.jht.2023.02.005)
• [L5] Differentiating a true boutonniere deformity from a pseudoboutonniere injury is critical in determining clinical management. [2] (10.1016/j.jhsa.2022.10.019)
• [L4] The natural history of the boutonnière deformity in rheumatoid arthritis is outlined, and a simple method of repair is described. [3] (10.2106/00004623-196951070-00009)
• [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. [4] (10.5435/jaaos-d-14-00272)
• [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. [5] (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. [6] (10.1016/j.jhsa.2021.01.003)
• [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. [7] (10.1016/s0749-0712(21)00060-3)
• [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] This article summarizes current concepts relating to the presentation and treatment of closed soft tissue injuries of the extensor mechanism in zones I, III, and V, commonly known as mallet finger, boutonniere deformities, and sagittal band injuries. [14] (10.1016/j.jhsa.2013.11.018)
• [L5] The boutonniere deformity requires subluxation of the lateral bands volar to the axis of rotation of the PIP joint. [15] (10.1016/j.jhsa.2017.07.011)
• [L4] Treating swan neck and boutonniere deformities of the PIP joint is a difficult challenge that requires understanding the cause, biomechanical changes, and articular status. [17] (10.1016/j.hcl.2017.12.006)
• [Paper] The article discusses injuries to the central slip (boutonniere) and annular pulleys in elite athletes, emphasizing the importance of anatomic knowledge, accurate diagnosis, and balancing early return to play with long-term risks. [18] (10.1016/j.hcl.2012.05.044)
• [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. [20] (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. [23] (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. [24] (10.1177/15589447221081876)
• [Paper] Extension of the PIP joint decreases as these structures are progressively damaged. [25] (10.1016/s0363-5023(12)60014-8)
• [L5] Asymmetrical position of the distal phalanges during extension suggests a central slip lesion, while symmetrical position indicates the lesion is unlikely. [28] (10.1177/175899830601100402)
• [L4] The prognosis is far better after irreducible than after reducible volar dislocations because the extensor mechanism is displaced, not disrupted. [31] (10.2106/00004623-197860010-00023)
• [L4] Congenital hypoplasia of the central slip can be treated successfully by using a static hand brace to keep the PIP joint in the extension position, especially with the frequent application of the hand brace. [35] (10.1177/1753193416676410)

References¶

[1] 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

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

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

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

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

[6] 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

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

[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

[14] Closed Soft Tissue Extensor Mechanism Injuries (Mallet, Boutonniere, and Sagittal Band). The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.11.018

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

[16] 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.

[17] Treating the Proximal Interphalangeal Joint in Swan Neck and Boutonniere Deformities. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.12.006

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

[20] 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

[23] 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

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

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

[26] Redistribution of Forces in the Correction of the Boutonniere Deformity.. The Journal of Bone and Joint Surgery. American Volume. 1967.

[28] A Modification Of Elson's Test For The Diagnosis Of An Acute Extensor Central Slip Injury. The British Journal of Hand Therapy. 2006. DOI: 10.1177/175899830601100402

[31] 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

[35] Successful conservative treatment outcomes and clinical characteristics of congenital hypoplasia of the extensor tendon central slip. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416676410