Boutonnière Deformity
Jacksonville, FL
The middle knuckle is stuck bent and the fingertip is hyperextended — boutonnière deformity. R. David Graham, MD at JOI manages both flexible and fixed boutonnière. Flexible deformities are corrected with splinting and therapy. Fixed deformities that have failed conservative management are addressed surgically — PIP fusion is the preferred procedure over arthroplasty for fixed boutonnière.
- PIP flexion contracture + DIP hyperextension = boutonnière pattern
- Caused by central slip disruption — lateral bands migrate volarly
- Flexible boutonnière: PIP still passively correctable — splinting + therapy
- Fixed boutonnière: PIP cannot be fully passively extended — surgical correction
- Preferred surgery for fixed boutonnière: PIP fusion (not arthroplasty)
- RA patients: boutonnière common — surgical management in context of systemic disease
Boutonnière deformity is the downstream consequence of missed or undertreated central slip injury. A flexible boutonnière that is caught early can recover fully with diligent splinting. A fixed boutonnière requires surgery — and PIP fusion, while sacrificing motion, provides a reliable, pain-free, functional finger.
Understanding Boutonnière
PIP Stuck in Flexion —
DIP Hyperextended
Boutonnière deformity is a characteristic finger posture produced by disruption of the central slip — the extensor tendon attachment at the PIP joint. When the central slip fails, the lateral bands of the extensor mechanism lose their dorsal stabilization and migrate progressively volarly (palm-ward) around the PIP joint. Now positioned volar to the PIP joint axis, the lateral bands convert from PIP extensors into PIP flexors. The PIP develops a flexion contracture. Simultaneously, the lateral bands, still dorsal to the DIP joint axis, create compensatory DIP hyperextension — the distal phalanx cocks up while the middle phalanx is stuck down.
Causes include missed central slip laceration, closed central slip rupture from forced PIP flexion, volar PIP dislocation with central slip avulsion, and rheumatoid arthritis (which erodes the central slip from synovial invasion). The deformity ranges from passively correctable (flexible boutonnière) to completely rigid (fixed boutonnière), and the treatment is determined by this distinction.
Flexible boutonnière — where the PIP can still be fully passively extended — is treated conservatively with continuous PIP extension splinting and active DIP flexion exercises. The DIP flexion exercise specifically pulls the lateral bands dorsally, which is the biological basis for recovering lateral band position without surgery. Diligent splinting for 6–8 weeks can fully correct flexible boutonnière when started early.
Fixed boutonnière — where the PIP cannot be fully passively extended due to contracted soft tissues — requires surgical correction when it is functionally limiting. In Dr. Graham's approach, PIP fusion is preferred over arthroplasty for fixed boutonnière. The reason: the deformity involves not just the joint but the extensor mechanism — simply replacing the joint while the imbalanced lateral bands are present risks recurrence or poor motion arc. Fusion provides a stable, pain-free, functional finger in a functional position. Arthroplasty is reserved for specific situations in the RA context where adjacent joints and the overall hand function dictate a different approach.
- ✓ Flexible: PIP passively correctable to full extension — splint + therapy
- ✓ Fixed: PIP cannot be fully passively extended — surgery when functionally limiting
- ✓ Surgery for fixed: PIP fusion in functional position (30–40° flexion)
- ✓ Why fusion over arthroplasty: lateral band imbalance persists — fusion eliminates the deforming force
- ✓ RA boutonnière: managed in context of overall RA hand reconstruction
- ✓ Duration of deformity matters: earlier treatment produces better results
Treatment
Flexible — Splint. Fixed — Fuse.
Assess: Flexible or Fixed?
Gently attempt passive PIP extension. If the PIP can be fully extended passively — the deformity is flexible and can be corrected conservatively. If there is a fixed flexion contracture that cannot be passively corrected — conservative management may still improve it somewhat, but significant fixed deformity is a surgical problem.
Flexible Boutonnière — Extension Splinting
Continuous PIP extension splint worn 24 hours a day. Active DIP flexion exercises performed hourly with the PIP held in extension — this mobilizes the lateral bands dorsally. Duration: 6–8 weeks minimum, longer for established deformities. Formal hand therapy guides splint fabrication and exercise progression. Many flexible boutonnière deformities fully correct with this protocol.
Fixed Boutonnière — PIP Fusion
When conservative management has failed and the fixed deformity is functionally limiting, PIP fusion in a functional position (30–40° of flexion) is performed. The articular surfaces are resected, the joint is positioned, and fixation is achieved with crossed K-wires or a headless compression screw. Healing takes 6–8 weeks. The result is a stable, pain-free finger in a position that allows grip and pinch — trading the lost motion for reliable function.
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Middle knuckle stuck bent —
earlier treatment is always better.
Flexible boutonnière corrects with splinting. Fixed boutonnière requires surgery. The longer a boutonnière is left untreated, the more fixed it becomes — early evaluation determines whether conservative treatment can still work.
Jacksonville Beach, FL 32250
No imaging required.