Boutonnière (buttonhole) deformity happens when an injury occurs to the tendons that allow a person to straighten the middle joint of their finger. Although several tendons operate the joints of the finger, the one that runs along the top of the finger is the one that must be impaired for this condition to occur. This injury can be caused by trauma, like jamming of the finger, a cut to the tendon, burns or infections, although these are less often seen. Much more commonly seen are Boutonnière deformities caused by rheumatic forms of arthritis. The outcome is that the fingertip will bend backwards while the middle joint of the same injured finger won’t straighten.
Even though the injury may be painful and the top of the joint may swell, the bending symptoms may take several weeks to manifest or they may develop immediately. As soon as the bending is recognized, it is important to be seen by an Orthopaedic physician so that the deformity does not progress and become permanent or impair function. If the bending goes untreated for longer than three weeks, it becomes more difficult to fully resolve when treatment is finally administered. In my Orthopaedic practice, I treat this condition regularly.
When I see a patient with suspected Boutonnière deformity, I will usually order x-rays to rule out fracture of the finger, which is common with this injury. I will also do a physical examination of the finger and hand. Treatment depends on how the injury occurred, if the bone is broken and how ago long the injury happened. I will ask about any recent injuries, burns, infections or if the patient has a history of rheumatic arthritis. I may order Lab Studies if infection or Rheumatoid Arthritis is the suspected cause. I will also ask the patient to actively move the finger and then I will move it to measure range of motion.
Conservative treatment for Boutonnière deformity may include an oral anti-inflammatory medication or I may give an injection of corticosteroid into the damaged tendon. I will also prescribe a splint to be worn for 4-6 weeks and exercises to increase strength in the finger. For those who participate in sports, the finger may need to be taped for protection after the splint is removed. I may also recommend that the splint be worn while sleeping for a longer period of time.
For those persons who do not respond to this treatment or who have moderate to severe rheumatoid arthritis, a large tear of the tendon or a large, displaced bone fragment, surgery is the preferred treatment. The main goals of surgery are to relieve pain and to improve function. However, surgery will not always restore the look of the finger to its pre-injury condition and there may be a permanent bend to the finger. This surgery is performed on an outpatient basis at an Ambulatory Surgery Center. Post-operatively, a splint will need to be worn and the patient will require physical therapy to regain a full range of motion and full use of the digit.
Complications are rare, but can include infection, loss of function or chronic pain, even reflex sympathetic dystrophy, a chronic pain syndrome. Sometimes, the first surgical attempt at repair does not fix the problem and the surgery must be done over or a new repair technique tried. In rare cases, the digit cannot be salvaged and must be amputated.
Thankfully, the advent of biologics has revolutionized the treatment of rheumatoid types of arthritis and the incidence of BD has decreased in patients who are receiving this therapy.
Robert J. Snyder, MD is an Orthopaedic Surgeon who practices at Orthopaedic & Spine Center in Newport News, VA. Voted a “Hampton Roads Top Doc” for 2012 and 2013 by his peers, Dr. Snyder specializes in Joint Replacement of the Knee and Hip, Sports Medicine and General Orthopaedics. For more information on Dr. Snyder or OSC, call 757-596-1900 or go to www.osc-ortho.com.