Boutonniere Deformity Research Articles

Fractional Fowler Tenotomy for Chronic Mallet Finger: A Cadaveric Biomechanical Study

The Fowler tenotomy, adjusting the balance of the extensor mechanism by central slip and lateral band detachment, is a common surgical technique for chronic mallet finger. The purpose of this study was to determine how much tendon to detach from the middle phalanx by measuring the extensor lag of the distal interphalangeal (DIP) joint following the procedure and to quantify how often a boutonniere deformity occurred as a consequence of the procedure. Sixteen fingers were obtained from 8 fresh-frozen cadaver hands. We made mallet finger deformity models by terminal tendon elongation. We detached the central slip and lateral band from the middle phalanx by one-third, one-half, and two-thirds of the phalangeal length and measured extensor lag of the DIP and proximal interphalangeal joints before and after this procedure. In these models, the average extensor lag of the DIP joint was 44° (range, 40° to 50°). After central slip and lateral band detachment over one-third of the phalangeal length, the average residual extensor lag of the DIP joint was 19° (range, 0° to 40°). With one-half detachment, the average lag was 13° (range, 0° to 35°), and with two-thirds detachment, the average lag was 6° (range, 0° to 15°). Extensor lag at the proximal interphalangeal joint occurred in 4 fingers, with an average lag of 8° (range, 5° to 15°). In the Fowler tenotomy models, detachment of the central slip and lateral band from the middle phalanx reduced extensor lag of the DIP joint. Detachment of up to two-thirds of the phalangeal length was effective in this model and did not cause any boutonniere deformity. Controlled clinical application of our cadaveric results might yield improved active motion for chronic mallet extensor lag.

The Athlete's Hand: Ligament and Tendon Injury

Hand injuries are common, accounting for up to 20% of emergency department visits nationwide. An understanding of the complex and detailed anatomical relationships of small joints facilitates the accurate diagnosis of many common sports-related injuries of the hand. We review the common ligamentous and tendinous injuries of the hand including collateral ligament injuries, gamekeeper's thumb, extensor mechanism injuries, pulley injuries, boutonniere deformities, and mallet and jersey lesions. The mechanism of injury, clinical presentation and treatment, pertinent anatomy, and imaging findings are discussed.

Biomechanics of the Acute Boutonniere Deformity: Not a clinical study

Biomechanics of the Acute Boutonniere Deformity: Not a clinical study

The use of Kinesiology Taping method in patients with rheumatoid hand – pilot study

Rheumatoid arthritis (RA) most frequently affects smaller joints in the hands and feet. Among the most common deformations resulting from the progression of the disease are ulnar deviation, Boutonniere deformity, swan neck deformity, contractures and limited range of movement in the hand and wrist joints, muscular atrophy of long and short muscles. The topic of this article is the influence of using Kinesiology Taping method on the functioning of the hand of the patient suffering from rheumatoid arthritis. The research involved 20 patients suffering from rheumatoid arthritis (16 women, 4 men), treated in the Hospital in Kup. Average age of patients was 62.2. Research subjects, apart from pharmacological treatment in the hospital ward, received standard physiotherapy. In case of 10 patients additional K-Active Tape applications were used to correct ulnar positioning of the hand and improve hand functioning. Prior to physiotherapy, all patients were given a hand functioning test and a dynamometer measurement was made. The tests were repeated after the 2-week rehabilitation process has been completed. The results were subjected to statistical analysis with the use of the Wilcoxon test and the U Mann-Whitney test. The assessment of the correlation between analysed parameters was made with the use of linear correlation test. In the group where Kinesiology Tape applications were used, hand muscle strength increased significantly (p<0.05) in comparison with the group treated with standard physiotherapy. Hand muscle strength increase correlated with the tempo of carrying out the hand functioning test (r>0.8). Results suggest Kinesiology Taping method useful for physiotherapy of rheumatoid hand.

SURGICAL MANAGEMENT OF CHRONIC BOUTONNIERE DEFORMITY

Boutonniere deformity is caused by damage to the central slip of the extensor tendon hood with secondary palmer migration of the lateral bands. Accordingly, patients complain of disfigurement and impairment of function due to hyperextension of their DIP. The aim of this study is to evaluate the results of surgical treatment of chronic boutonniere deformity by using a modified technique. Twelve patients with posttraumatic boutonniere deformity were available for follow up as a retrospective study. They were treated by release of the extensor expansion proximal to the distal insertion of the oblique retinacular ligaments with proximal recession of the extensor tendon and lifting the lateral bands dorsally onto the PIP joint after separation of the transverse retinacular ligaments from their insertion volarly. All patients had closed injury. The mean age was 32 years (range: 16-48 years). The average follow-up period was 33 months (range: 26-38 months). We included only cases with deformities that were totally correctable passively with or without joint osteoarthritic changes. Preoperatively the average PIP joint extension deficit was 60° and postoperatively the average is reduced to 7°, preoperative the average DIP motion was 10° of hyperextension, post-surgery the average DIP active flexion was 75°. The final outcomes were 58.3% excellent, 33.3% good, and 8.3% poor. This modified technique gave (91.6%) excellent and good results. The extensor tendon acted mainly on the PIP joint and allowing the DIP joint to flex freely. The procedure is simple and provides long-term good results. Therapeutic case series, level 1V.

Pediatric Boutonniere Deformity After Blunt Closed Traumatic Injury

The boutonniere deformity (BD) is a well-described condition in hand surgery. Treatment of acute traumatic BD includes splinting of the proximal interphalangeal joint in extension for 4 to 5 weeks, which often leads to acceptable results. However, the chronic BD is more problematic and often requires surgical intervention with poor functional outcomes. Boutonniere deformity is extremely rare in the pediatric population. We present the case of a 9-year-old girl who presented to the emergency department with an acute traumatic BD after a fall. Being an uncommon entity in this patient population, the patient was referred to the plastic surgery clinic and was subsequently treated appropriately with splinting, resulting in favorable results as early as 4 weeks. To our knowledge, this is the first reported case of BD in the pediatric patient population. Recognition and timely management of BD in a pediatric patient should not be overlooked to obtain favorable results.

Tendon Disorders of the Hand

After reading this article, the participant should be able to: 1. Make decisions on flexor tendon repair based on current evidence. 2. Perform some important tendon transfers after viewing Dr. Kozin's videos. 3. Inject local anesthesia for wide-awake flexor tendon repair after viewing the appropriate videos in the article. 4. Use relative motion extension splints for the postoperative management of extensor tendon injuries. This article provides a practical, clinically useful overview of some of the current best techniques and evidence available to the plastic surgeon in the treatment of flexor and extensor tendon injuries, tendon transfers, trigger fingers, mallet fingers, boutonniere deformities, and De Quervain tenosynovitis. Twelve short movies and drawings emphasize important points of diagnosis and treatment of tendon disorders.

Treatment of Bony Boutonniere Deformity with a Loop Wire

Boutonniere deformity associated with a dorsal avulsion fracture of the central slip overlying the proximal interphalangeal joint results in loss of extension of the joint and hyperextension of the distal interphalangeal joint. This article reports a surgical technique for treatment of the injury in 21 digits, which involves application of loop stainless steel wire. We also present the long-term results using the technique on the digits. Loop wire fixation is a successful surgical technique for the treatment of displaced central slip avulsion fracture.

Operative Eingriffe an Hand und Handgelenk

Despite improved medical treatment of rheumatoid arthritis, carpal tunnel compression, caput ulnae syndrome and palmar and dorsal tenosynovitis with potential tendon rupture represent urgent surgical indications. While diagnostic and therapeutic synovectomy may guide medical treatment, it should be performed before joint instability and destructive arthritis are established. Swan-neck and Boutonniere deformities as well as ulnar or radial drift of metacarpophalangeal (MCP) joints or the wrist can only be corrected when the involved joints are supple and intact. In the presence of destructive arthritis, partial and total wrist fusion, arthroplasties of the MCP joints and arthrodeses of the distal interphalangeal joints are recommended.

Boutonniere Deformity

A 30-year-old man presents to the office 6 weeks after a softball jammed the right, dominant index finger. He was referred to the hand clinic with a 35° extensor lag of the proximal interphalangeal (PIP) joint (boutonniere deformity) that is passively correctable. •Discuss the results of nonsurgical treatment of central slip injuries with respect to timing of intervention. •Describe the Matev rebalancing technique for lateral band reconstruction and the various iterations. •State the location of the Dolphin extensor tenotomy to treat Boutonniere deformity. •Summarize the role of the transverse retinacular ligaments in the established Boutonniere deformity. •Discuss the complications of Boutonniere surgery. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month’s test, visit http://www.assh.org/professionals/jhs. •Discuss the results of nonsurgical treatment of central slip injuries with respect to timing of intervention. •Describe the Matev rebalancing technique for lateral band reconstruction and the various iterations. •State the location of the Dolphin extensor tenotomy to treat Boutonniere deformity. •Summarize the role of the transverse retinacular ligaments in the established Boutonniere deformity. •Discuss the complications of Boutonniere surgery. Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month’s test, visit http://www.assh.org/professionals/jhs. JournaL CME QuestionsJournal of Hand SurgeryVol. 36Issue 1Preview Full-Text PDF

541 The Diagnosis and Treatment Particularities in a Case with Juvenile Idiopathic Arthritis

Background and aims: To emphasize the diagnosis peculiarities and treatment difficulties in a case with joint pains. Methods: The authors present a 15 year-old girl admitted for chronic limping. Personal history: morning stiffness and progressive walking difficulties due to arthralgia during last 12 months, progressive regression in motor skills. The girl has followed a chronic therapy with retard penicillines because of persistent high ASLO titer (rheumatic fever suspicion). Clinical exam: impaired nutritional status (- 3 SD), symmetric joint involvement: pain and swelling for proximal interphalangeal hand joints, metacarpophalangeal joints, wrists, knees, ankles and temporomandibular joints, boutonniere deformities and ankylosis for hand fingers, hands and legs muscles atrophy. Results: Laboratory investigations: elevated inflammatory markers, negative rheumatoid factor, positive antinuclear antibodies, high ASLO titer, hypergammaglobulinemia. The imagistic approach: periarticular osteoporosis (wrist radiographs), narrowed joint spaces and erosions. Synovial biopsy has revealed suggestive features for juvenile idiopathic arthritis (JIA). According to diagnosis, the treatment has included physical therapy, anti-inflammatory drugs and methotrexate. Even under methotrexate therapy, the joint function has deteriorated with hand fingers progressive ankylosis. The biologic therapy (etanerceptum) has been initiated with improvement of joint mobility, synovial inflammation and osteoporosis, too. Conclusions: The patient was misdiagnosed as rheumatic fever due to high ASLO titers that can be explained by polyclonal and non-selective B lymphocytes activation. In this case, ASLO titer was correlated with disease's activity. The case peculiarity: it's important to consider the JIA diagnosis for cases with persistent high ASLO titers and unresponsiveness to penicillin therapy.

Commentary on an article by R.W. Draeger, MD, et al.: “Corticosteroids as an Adjunct to Antibiotics and Surgical Drainage for the Treatment of Pyogenic Flexor Tenosynovitis”

Pyogenic flexor tenosynovitis, or suppurative flexor tenosynovitis, is a closed-space bacterial hand infection of the digital flexor tendon sheath that can cause considerable morbidity. The majority of these infections follow traumatic penetrating injuries; therefore, skin flora, including Staphylococcus aureus, are the most common infecting organisms1. Kanavel classified this condition among the grave infections of the hand, describing the classic cardinal signs of flexor sheath infections, including pain with passive extension of the digit, symmetric digital swelling (sausage digit), tenderness along the flexor sheath, and a semiflexed resting posture of the involved digit1. A high (38%) rate of complications, including stiffness, persistent infection, boutonniere deformity, and amputation, has been reported2. Several risk factors have been associated with poor outcomes following the treatment of pyogenic flexor tenosynovitis, including an age of more than forty-three years, the presence of diabetes mellitus, peripheral vascular disease, renal failure, the presence of subcutaneous purulence, digital ischemia, polymicrobial infection3, methicillin-resistant Staphylococcus aureus infection, and delay in diagnosis4. Nonoperative treatment with intravenous antibiotics may be possible if the infection is detected …

Design and Preliminary Evaluation of a Novel Brace for Boutonniere Deformity

Boutonniere deformities are a common injury to the extensor mechanism of the finger. The deformity results in fixed contraction in the middle finger joint and is severely debilitating to functionality. Due to the complexity of the extensor mechanism, surgical repair is difficult, which usually requires multiple procedures, and in some cases is unsuccessful. Nonsurgical treatment of the deformity has not dramatically improved in many years and usually requires long-term use of braces and physical therapy. This work is focused on design and preliminary evaluation of an improved boutonniere brace to correct the deformity with emphasis on lower costs, integrating therapeutic techniques such as heat and motion to increase blood flow and patient comfort. A review of the current state of the art is presented along with the design approach used to develop an improved device. Experimental test results are also presented. This work demonstrates a new device and approach for treatment of boutonniere deformities that may translate to treatment of other conditions such as arthritis.

Flexion contractures of fingers: Contracture elimination with trapeze-flap plasty

Scar flexion contracture of fingers is one of the most serious consequences of hand burns and patient disability after burn. Many kinds of reconstructive techniques are currently used and new procedures are being investigated. The author presents a new method of finger contracture reconstruction developed in the process of burn reconstructive operations on hands of over a thousand patients. Finger flexion contractures are caused by a semilunar fold, both sheets of which are scars. The sheets have a surface deficiency in length, which causes a contracture, and excess of skin in width, which allows contracture elimination with local flaps. The length deficiency extends from the crest of the fold to the joint rotation axis and has a trapezoid form. To compensate for skin deficiency and to address the contracture, it is necessary to convert both fold sheets into trapezoid flaps by radial incisions. Because the fold is of semilunar (crescent) shape, the flaps accept a trapezoid form. One or several pairs of the flaps are mobilized with the split fat layer from the fold's crest to the joint rotation axis level. The oppositely transposed flaps fully or partially cover the wound in the proximal interphalangeal (PIP) zone first. The remaining smaller wounds are covered with full-thickness skin grafts. The flaps have a reliable blood circulation; partial flap loss is an exception. The flap's surface does not decrease, the skin grafts shrink insufficiently, and the distant results, as a rule, are good. Two hundred and seventy-five patients were operated upon. Scar contractures were satisfactorily addressed in all patients. Incomplete extension was found in 46 patients; this was caused by interphalangeal joint injuries (ligaments, capsule, cartilage), ankylosis or boutonniere deformity.

Solitary Intra-Articular Osteochondroma of the Finger

A solitary osteochondroma of the finger occasionally occurs intra-articularly and may cause clinical symptoms, including limited motion and deformity. The present report describes the clinical features and the results of operative treatment for a series of patients who had a solitary intra-articular osteochondroma of the finger. Ten patients with a solitary intra-articular osteochondroma of a phalanx of a finger were managed surgically. Eight patients were male, and two were female. The average age at the time of surgery was fourteen years. Treatment consisted of mass excision for three patients and mass excision with corrective osteotomy for six. One additional patient had a boutonniere deformity and underwent extensor tendon reconstruction combined with mass excision. The average duration of follow-up was forty-four months. The proximal phalanx was affected in six patients, and the middle phalanx was affected in four. All tumors involved the distal epiphysis. All patients had postoperative improvement in terms of deformity and/or limitation of motion. Six patients had a preoperative mean coronal plane deformity of 29 degrees, which improved to 4 degrees after surgery. The preoperative mean arc of flexion-extension improved from 54 degrees to 78 degrees in four patients who had a motion deficit at the proximal interphalangeal joint and from 60 degrees to 80 degrees in one patient who had a motion deficit at the distal interphalangeal joint. Two patients had a residual flexion contracture, one with preexisting osteoarthritis and one with a longstanding progressive boutonniere deformity. There were no other complications or recurrences. Isolated intra-articular osteochondroma of the finger can cause deformity and/or motion limitation. Early mass excision and corrective osteotomy when indicated are recommended to restore full range of motion and to prevent osteoarthritis and secondary deformity.

0614: Pulleys, Plates and Other Paraphernalia - Anatomy and Unique Injuries to Fingers

The digits of a hand have 17 articulations and unique tendon anatomy. Assessment of injuries to these structures requires an understanding of the anatomy. Finger Flexor Mechanism At the level of the wrist, the FDS and FDP tendons are contained within a common synovial sheath. This ends at the level of the mid metacarpals except for the little finger where it is usually continuous with its digital sheath. An effusion around the little finger flexor tendons within the digit may reflect more proximal pathology. The digital flexor tendons are held in osseo-aponeurotic canals by fibrous sheaths from the metacarpal heads to the base of the terminal phalanx. Thickened zones of the sheath are termed pulleys, which may be annular or cruciate. The most clinically important of these are the A1 and A2 pulley. Thickening of the A1 pulley is one of the many aetiologies of trigger finger. The A2 pulley has recently been described in cadaver study as hyperechoic, but in-vivo is hypoechoic. Disruption of the A2 pulley results in “bowstringing” of the flexor tendons. A4 pulley ruptures are also relatively common. Finger Extensor Mechanism There is a fibrous expansion on the dorsum of each digit, which extends distally from the metacarpal head and blends with the extensor digitorum tendon. The tendon is stabilized on the metacarpal head by components of the extensor hood, including sagittal bands which extend anteriorly to the volar plate. Dorsal hood injuries usually involve the radial sagittal band, resulting in ulnar subluxation of the common extensor and ulnar deviation of the proximal phalanx. As the extensor digitorum tendon approaches the PIP joint, it divides into an axial part, which inserts into the base of the middle phalanx and two collateral slips. Disruption of the axial portion results in a Boutonniere deformity. The collateral slips of the extensor tendon then unite to be attached to the dorsal aspect of the base of the distal phalanx. Disruption of this attachment results in mallet finger. Articulations The volar plate is a fibrocartiliginous plate that forms the floor of the MCP, PIP and DIP joints. At the PIP joint it provides significant stability and disruption, almost universally at its distal attachment, predisposes to recurrent dorsal dislocation. The collateral ligaments of the articulations are thick cords which attach to a posterior tubercle at the head of the proximal structure and pass obliquely forwards to the base of the distal structure - an important concept in identifying these structures. Sonographic findings in collateral ligament injuries will be discussed with emphasis on the thumb UCL and Stener lesion.

Boutonniere deformity of the second toe after planter dislocation of proximal interphalangeal joint: a case report

The boutonniere deformity is a well-known deformity in the fingers, however, its appearance on a lessor toe is extremely rare. In the present case, the deformity resulted from a rupture of the central slip of the extensor tendon and the shift of the lateral bands to the planter side after reduction of a traumatic planter dislocation of the PIP joint of the second toe. Surgical repair of the extensor mechanism brought good results.

Functional thumb orthosis for type I and II boutonniere deformity on the dominant hand in patients with rheumatoid arthritis: a randomized controlled study

Objective: To evaluate the effectiveness of a functional thumb orthosis on the dominant hand of patients with rheumatoid arthritis and boutonniere thumb. Methods: Forty patients with rheumatoid arthritis and boutonniere deformity of the thumb were randomly distributed into two groups. The intervention group used the orthosis daily and the control group used the orthosis only during the evaluation. Participants were evaluated at baseline as well as after 45 and 90 days. Assessments were preformed using the O'Connor Dexterity Test, Jamar dynamometer, pinch gauge, goniometry and the Health Assessment Questionnaire. A visual analogue scale was used to assess thumb pain in the metacarpophalangeal joint. Results: Patients in the intervention group experienced a statistically significant reduction in pain. The thumb orthosis did not disrupt grip and pinch strength, function, Health Assessment Questionnaire score or dexterity in either group. Conclusion: The use of thumb orthosis for type I and type II boutonniere deformities was effective in relieving pain.

(iii) Twenty questions on tendon injuries in the hand

Summary Recovery to full function following a tendon injury in the hand continues to be a challenge; therefore, the surgeon requires a detailed knowledge of anatomy, tendon healing, repair techniques, injury patterns and evolving rehabilitation methods to best treat these injuries. Particularly with flexor tendon injuries, current surgical techniques have significantly decreased rupture rates and controlled postoperative mobilization has reduced tendon adhesions that historically complicated repair attempts. In addition to open flexor and extensor tendon lacerations, this review also discusses closed tendon injuries in the hand, including flexor digitorum profundus (FDP) and extensor pollicis longus (EPL) ruptures, and mallet and boutonniere deformities.

Jaccoud Arthropathy in Systemic Lupus Erythematosus

Jaccoud arthropathy (JA) was initially described in patients with rheumatic fever and later in several other rheumatologic conditions, particularly systemic lupus erythematosus (SLE). In patients with the latter disorder, a prevalence of about 5% has been observed. We conducted the current study to describe a series of patients with SLE with JA, followed at the Hospital Santa Izabel, Salvador, Brazil, during the year 2006. We reviewed the literature on JA, with emphasis on the histologic, clinical, radiologic, and therapeutic aspects of the condition. Twenty-one patients with JA were identified, corresponding to a prevalence of 3.47% in the population of 606 patients with the diagnosis of SLE attended in our service. Twenty patients were women, and the mean age was 40.2 +/- 8.8 years (range, 24-55 yr). The most frequently found joint deformities were swan neck and thumb subluxation, both identified in 14 patients. Ulnar deviation was seen in 8, boutonniere deformity in 3, and hallux valgus in 2 patients. We found no difference in the clinical or laboratory features in SLE patients with or without JA. The patients with JA presented a trend toward a lower quality of life compared with the patients with SLE without JA, but without statistical significance.