- See:
-
Boutonnere Injuries - Menu
-
Thumb Boutonnere Deformity
- Discussion:
- rheumatoid boutonniere deformity begins w/ PIP synovitis & elongation capsule;
- inflammation leads to lengthening of central extensor slip and triangular ligament (becoming dysfunctional) and volar displacement
of the
lateral bands (which leads to subsequent contracture of
transverse retinacular fibers);
- later there is attenutation of central slip & triangular ligament to allow volar subluxation of
lateral bands;
- lateral bands then become flexors of PIP joint;
- Stage 1:
- 10-15 deg flexion deformity & extensor lag of PIP joint is passively correctable;
- as PIP joint deformity is corrected, limited flexion of DIP will be noted;
- consider dynamic splinting, & lateral band reconstruction (relocation dorsal to axis of rotation);
- consider terminal extensor tendon tenotomy to improve DIP flexion;
- this procedure is based on idea that oblique
retinacular ligament acts to extend the DIP joint;
- Stage 2:
- moderate deformity (PIP flexion deformity 30-40 degrees, flexible joint, preservation of joint space on X-ray);
- pts w/ this deformity may compensate w/ MCP joint hyperextension;
- terminal extensor tendon tenotomy to allow DIP flexion;
- consider synovectomy;
- central slip reconstruction and shortening;
- lateral band reconstruction w/ release of
transverse retinacular ligament;
- postoperatively, PIP is held in extension w/ a K wire for 3 weeks;
- Stage 3:
- fixed deformity w/
retinacular ligament tightness;
- contracture and tightness of
ORL and
TRL;
- deformity:
-
ORL: maintains DIP extension, blocks flexion;
-
TRL: maintains volar subluxation of lateral bands, PIP flexion
- these patients may or may not feel that they have a functional deficit;
- be careful to replace a functional flexion contracture with a poorly functioning stiff extended finger;
- treatment spinting to restore PIP to full passive extension (may require serial casting);
- active and passive ORL stretching, proceed as in stage II when the PIP is fully extended;
- no reconstructive procedures should be tried, until passive ROM is restored;
- if there is loss of articular cartilage, consider fusion for this deformity;
- Arthoplasty;
- indicated for painful & stiff joint w/ x-ray evidence of joint destruction;
- for deformities of more ulnar PIP joints;
- PIP joint of the index finger does better w/ fusion in 20 to 40 deg flexion;
- more stable index finger can be used in pinch and the more flexible middle finger can be used in grasp;
Surgical treatment of the boutonniere deformity in rheumatoid arthritis.
Nalebuff EA, Millender LH: Orthop Clin 6:753-763, 1975
