What is the management of Boutonniere deformity?

Management of Boutonniere Deformity

The most effective management of Boutonniere deformity involves early intervention with custom splinting to prevent PIP hyperextension while allowing flexion, combined with hand therapy to maintain joint range of motion for mild, flexible deformities. 1

Understanding Boutonniere Deformity

• Boutonniere deformity consists of flexion of the proximal interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joint 2
• It can result from disruption or laceration of the central slip of the extensor tendon at the PIP joint with volar displacement of the lateral bands 3

Assessment and Classification

• Treatment decisions should be based on:
  • Degree of joint deformity
  • Available joint motion
  • Passive joint correctability
  • Status of the articular surface 2
• It is essential to distinguish between supple (flexible) and stiff (fixed) deformities 3

Conservative Management

For Acute/Flexible Deformities:

• Custom splinting to prevent PIP hyperextension while allowing flexion is recommended 1
• Treatment should be initiated within 6 weeks of injury for optimal outcomes 4
• Daily static stretching exercises when pain and stiffness are minimal 5
• Application of superficial moist heat before exercises to improve effectiveness 6
• Maintaining terminal stretch position for 10-30 seconds before slowly returning to rest position 6
• Relative motion flexion splinting:
  • Places the injured digit in 15-20° greater metacarpophalangeal flexion than neighboring digits
  • Permits full active range of motion and functional hand use
  • Should be maintained for 6 weeks in acute cases 7

For Chronic/Stiff Deformities:

• Serial casting to obtain as much PIP extension as possible (at least -20°) 7
• Following casting, relative motion flexion splinting and hand use for 12 weeks 7
• Resting hand/wrist splints combined with regular stretching 5

Surgical Management

• Indicated for severe established contractures that don't respond to conservative measures 5
• Options based on deformity classification:

For Moderate Deformities:

• Synovectomy and extensor tendon reconstruction for supple deformities with normal PIP joint 3
• Success rate of approximately 90% for reconstruction of the extensor apparatus in supple deformities 3

For Advanced Deformities:

• For rheumatoid arthritis-related deformities, the Littler procedure (oblique retinacular ligament reconstruction) is a first-line surgical option 1
• For destroyed PIP joints (osteoarthritis), silicone spacer implantation may be considered 3
• Arthrodesis (fusion) may be necessary in some cases of severe deformity 2

Rehabilitation After Treatment

• Hand therapy to maintain joint range of motion is essential 1
• Submaximal and aerobic exercise should be implemented, avoiding excessively strenuous exercise 6
• Adequate rest during exercise and monitoring of patient response is necessary 6

Common Pitfalls and Special Considerations

• Poor outcomes are associated with:
  • Absence of appropriate physical therapy 3
  • Secondary infection 3
  • Secondary rupture of surgical repairs 3
  • Delayed treatment (beyond 6 weeks from injury) 4
• Boutonniere deformity should be distinguished from contractures caused by neurological conditions 5
• Surgery should be performed by surgeons with expertise in hand deformities 1

Prognosis

• Improvement in digit range of motion is associated with initiation of treatment within 6 weeks 4
• Deformity from inflammatory arthritis is less likely to respond to conservative treatment 4
• Chronic boutonniere deformity can respond well to relative motion flexion splinting if serial casting can achieve adequate PIP extension 7