Boutonniere deformity

Background

• Extensor Zone III Injury over the PIP joint.
• Most commonly central tendon is injured, causing FDS to be unopposed, thus causing flexion of PIP
  • Disruption of central tendon causes lateral bands to be displaced volarly, causing them to act like flexors
• FDP still intact

Clinical Features

• History of trauma to digit and painful PIP.
• Forced flexion of actively extended finger
• Direct blow to PIP
• Jamming
• Laceration distal to PIP can injure central tendon
• On exam, will see hyperflexion of PIP with hyperextension of DIP and MP joints.

Differential Diagnosis

• Rheumatoid Arthritis
• Volar PIP dislocation
• Flexion contracture of PIP joint

Hand and finger injuries

• Radiograph positive
  • Hand and finger fractures
  • Hand and finger dislocations
  • Triquetrolunate ligament instability
• Radiograph negative
  • Dupeytren contracture
  • Boutonniere deformity
  • Hand and finger tendon injuries
  • Ganglion cyst
  • De Quervain tenosynovitis
  • Intersection syndrome
  • Drummer's wrist
  • Extensor digitorum tenosynovitis
  • Vaughn Jackson syndrome
  • Snapping Extensor Carpi Ulnaris
  • Compressive neuropathy, "bracelet syndrome"
  • Scaphoid fracture
  • Osteoarthritis
  • Infiltrative tenosynovitis
  • Gout
  • Rheumatoid arthritis
  • Trigger finger
  • Mallet finger
    • Swan neck deformity
  • Jersey finger
  • Jammed finger
  • Subungual hematoma
  • Fingertip laceration
  • Metacarpophalangeal (MCP) ulnar ligament rupture (Gamekeeper's thumb)
  • Nail avulsion
  • High-pressure injection injury

Evaluation

• Elson’s test: bend PIP 90 deg over edge of table, extend middle phalanx against resistance. Should have weak PIP extension and DIP goes rigid as lateral bands have to work.
  • Positive test indicated rupture of central tendon slip.

Management

• XR to assess for avulsion fracture of middle phalanx
• If open or with displaced avulsion fracture: operative repair
• Closed: splint in extension (Both DIP and PIP) for up to 6 weeks, refer to hand surgeon. NO flexion of DP permitted for duration of splinting, including during cleaning. Repair extensor tendon if injured.

Disposition

• Hand specialist follow up if closed injury
• Immediate consult if deformity is caused by open injury

See Also

• Hand and finger diagnoses

References

Authors

Hemang Acharya, Ross Donaldson, Neil Young, Ted Fan