Hand Surgery Source

Boutonniere - Observation

Test, Exam and Signs

Historical Overview

  • Boutonniere deformity is derived from the French word “boutonniere,” meaning button hole.  When this occurs in a finger the head of one of the proximal phalanx pops through the opening in the extensor hood, as though bone is popping through a button hole.

Description

  • Boutonniere deformity is an extensor tendon injury characterized by proximal interphalangeal joint (PIP) flexion and distal interphalangeal (DIP) joint extension.  As the disease progresses, the deformity becomes a permanent fixed PIP flexion contracture. 

Pathophysiology

  • Boutonniere deformity arises from articular erosions and soft-tissue laxity.
  • Boutonniere deformity also arises from injuries to the extensor tendon hood at the PIP.
  • The injury often is a traumatic rupture or laceration of the extensor hood.

Instructions

  1. Ask the patient to extend his/her affected finger and observe the lack of PIP joint  extension.
  2. Extend the finger passively to evaluate whether there is an extension lag or fixed contracture.
  3. Observe patient’s range of motion, i.e. extension and flexion of PIP joint and DIP joint.

Variations

  • The boutonniere can be a PIP joint extension lag where the joint can be passively extended by the examiner or a fixed contracture of the joint that can not be actively or passively extended.

Related Signs and Tests

  • Extensor tendon exam
  • Intrinsic muscle testing
Presentation Photos and Related Diagrams
  • Boutonniere
    Boutonniere
  • Boutonniere
    Boutonniere
Definition of Positive Result
  • A positive result occurs when the patient exhibits PIP flexion with or without DIP hyperextension.  
Definition of Negative Result
  • A negative result occurs when the patient does not exhibit PIP flexion and DIP extension and has a normal range of motion equal in both the right and left hands.  
Comments and Pearls
  • Boutonniere deformity usually only affects one finger, but multiple affected fingers can also occur.
  • In patients with rheumatoid arthritis, joint involvement is often distributed symmetrically. 
  • Congenital boutonniere deformity indicates embryonic developmental failures and is rare except in the fifth finger where the deformity is call camptodactyly. 
Diagnoses Associated with Tests, Exams and Signs
References
  1. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple.  New Jersey: SLACK Incorporated, 2012.
  2. Kim, Go, Hwang, et al.  Restoration of the Central Slip in Congenital Form of Boutonniere Deformity: Case Report. J Hand Surg Am 2014; 39(10):1978-81. PMID: 25042044
  3. To P, Watson JT.  Boutonniere Deformity. J Hand Surg Am 2011; 36(1): 139-42. PMID:  21193133
  4. Williams K, Terrono AL. Treatment of Boutonniere Finger Deformity in Rheumatoid Arthritis. J Hand Surg 2011;36(8):1388-93.  PMID: 21741772