1. science
2. medicine
3. surgery

Chapter 6
Boutonniere deformity
Ray A. Elliott,
Jr., M.D.
A flexion deformity of the proximal inter.phalangeal (middle) joint with extension
hyperextension
of the metacarpophalangeal
(proximal) and distal interphalangeal
(distal).
joints in the absence of a bone block or de.~ange..
ment of the flexor mechanism has long been con-.
sidered pathognomonic of thd buttonhole
or
boutonniere deformity of the finger.
One of the earliest descriptions of the button-.
hole deformity of the extensor mechanism was
detailed
by Gustav Hauck 12 in 1923. Using
models and cadaver specimens he demonstrated.
the anatomy and pathologic physiology of this
intriguing
entity. The more recent studies of
Kaplan, 14"16 Bingham and Jack, 2 Montant and
Baumann,e4,2~ Bunnell, ~’~ Landsmeer, 18 Stack,2~
Tubiana and Valentin, ~1,32 Milford, ~ and Zancolli ~6 have added greatly to our understanding.
Of these major contributions, the clear descriptions of the retinacular
system of ligaments by
Landsmeer and by Milford have been outstanding. We are now in a much better position to
understand and explain the mechanism of the
deformity and to have some explanation for the
apparent success of various methods of treatment
and the failure of others. Kaplan credits Weirbrecht (1742) with the first description of these
important ligaments.
Amongthe earliest
treatment methods were
the reports of Masone° (1930) and Milche~ (1931),
who both advocated prompt operation with repair of the buttonhole defect in the central slip.
Mason also approximated the lateral
bands in
the midline,
a technique
followed later by
Kaplan, 14 Montant and Baumann,2~ and others.
This symposium faculty was charged with presentation
of their own methods of management
rather than discussing the methods of others,
42
.
but I would be remiss if I failed to acknowledge
the background and experience gained from Dr’.
Boyes~ during the latter half of 1959. Although
he favors splinting rather than surgery for most
cases, the anatomic repair which he advocates
for a "long standing deformity in a young person" is the same repair technique that I have
used .since 1961 for the correction of the established mobile deformity of more than 2 weeks’
duration.
This technique has been used in patients up to 51 years of age. Perhaps we vary only
in our definitions
of "long-standing"
and
"young."
I hope that this presentation will renew interest in early operative management of selected
cases. The techniques to be presented here are
essentially
unchanged from those I presented to
the American Society for Surgery of the Hand
in 1965.7
BASIC CONSIDERATIONS
Essentials of anatomy
The exhaustive studies of the men named in
the opening paragraphs may be referred to for
the minute details of anatomy and physiology of
the extensor mechanism of the fingers. To under-.
stand the buttonhole deformity, however, the
surgeon must appreciate certain structures
and
fundamental relationships from these writings.
The central band. The central band of the
extensor hood of the finger is a continuation of
the extensor communis tendon beyond its vari-.
able insertion ~ on the proximal end of the proximal phalanx. The majority of the central tendon
fibers end in the distal part of the middle joint
capsule with a bony insertion on the base of the
middle phalanx. 1~
The lateral bands. The lateral
bands ex-
Boutonnieredeformity
change components with the central band but
are predominantly the tendinous extensions of
the lumbrical and interosseous muscles. They
unite distal to the middle joint at the triangular
ligament area and form a terminal extensor tendon, which blends with the capsule of the distal
joint and inserts on the base .of the distal phalanx.
The extensor expansion. The tendinous
componentsof the extensor mechanismare joined
by an aponeurotic expansion, and together they
form the extensor hood. Although the hood may
move as one unit, the freedom of independent
action of the componentssuggests some elasticity
29
of the tissue between them.
The retinacular ligaments. The retinacular
ligaments emphasized by Landsmeer, is which
often bear his name, arise from the proximal
phalanx and flexor tendon sheath in the volar
compartment. The transverse fibers pass through
a windowin Cleland’s ligament at the level of
~3
the middle joint to insert on the lateral bands.
The deeper and more tendinous oblique fibers
have a broad insertion on the side of the lateral
bands from the level of the middle joint to the
midportion of the middle phalanx. 31 These elements are referred to as the transverse and
oblique retinacular ligaments to denote their
anatomic and physiologic differences.
Essentials of physiology
t~
The excellent motion studies of Hauck,
Bunnell, ~ Landsmeer, 18 Stack, ~7 Tubiana and
Valentin, ~ and Zancolli, ~6 and the electromyographic studies of Backhouseand Catton t should
be reviewed for their detail. The surgeon interested in the treatment of the boutonniere deformity must understand a certain minimumof
these dynamic actions.
Function of commonextensor. The primary
action of the extensor communistendon is extension of the proximal phalanx. However, with the
proximal joint in extension or flexion and hyperextension blocked, this tendon can also extend
the middle and distal phalanges. ~6 If the proximal joint hyperextends, as in the claw deformity
of ulnar palsy, the long extensor tendon is unable
to extend the distal two phalanges against nor~
mal flexor tone.
Function of interossei. Normally, the extensor hood is free to slide proximally and distally
with extension and flexion of the proximal joint.
With the hood in the distal position, the interossei contribute to flexion of~the proximal joint
43
with little effect on the middle and distal joints.
With the hood in the proximal position and the
proximal joint stabilized in extension, the interossei can act through the lateral bands to extend
the middle and distal phalanges.
Function of lumbrlcals. The lumbrical muscles¢ like the interossei, are flexors of the proximal
phalanx. In contrast, however, they are effective
extertsors of the middle and distal phalanges
regardless of the position of the proximaljoint. 1
If the lumbricals and interossei exert their force
to hold the proximal joint in flexion, the common
extensor tendon is free to exert its maximum
effect; through the aponeurosis to extend the
~
two distal joints.
Lateral band shift. The two lateral bands,
whiclh normally lie dorsal to the axis of motion
of the middle joint, shift volarward wheneverthe
middle joint flexes. The intact triangular ligame.m:limits the extent of the shift and prevents
tlhese bands from becomingflexors of the middle
joint. This volar shift permits flexion of the distal
~
joint during active flexion of the middle joint.
Function of retinacular ligaments. The
transverse fibers of the retinacular ligament produce the traction force for the volar shift of the
~
lateral bands during flexion of the middle joint.
These same fibers prevent the lateral bands from
slipping toward the midline during extension of
the middle joint.
The oblique fibers of the retinacular ligament
exert their pull on the distal phalanx through
their insertion on the conjoined lateral bands.
Functionally these fibers lie volar to the axis of
~notion of the middle joint and dorsal to the axis
of motionof the distal joint. Active flexion of the
distal joint tenses the oblique fibers and tends to
pull the middle joint into flexion. With both
interphalangeal joints in the flexed position,
passive extension of the middle joint tenses the
obliclue fibers and tends to extend the distal
~
joint.
Tendon healing. Tendons severed in paratenon do not separate widely. The ends proliferate: actively in search of each other--sometimes
bridging the gap successfully with scar, but more
often becoming adherent to all surrounding
structures.
EVALUATION OF THE DEFORMITY
Pathologic physiology
C, reating the deformity. Whencontinuity of
the central extensor tendon is interrupted at the
44
Symposium on the hand
level of the middle joint, the middle phalanx is
pulled into flexion by the strong sublimis flexor
tendon. The head of the proximal phalanx may
herniate through the tendon defect between the
intact lateral
bands, much as a button passes
through a buttonhole.
Initially, or soon after injury, the triangular
ligament splits longitudinally,
permitting the
lateral bands to spread apart and shift volarward. 25 Whenthey slip below the axis of motion
of the middle joint they become flexors. Efforts
to extend the finger increase the tension on the
lateral
bands, producing flexion of the middle
joint and extension or hyperextension of the distal
joint. Tension on the lateral bands is also increased by the proximal retraction of the divided
or stretched central tendon, further aggravating
the deformity. Active flexion of the distal joint is
difficult in the face of this increased tension and
both active and passive flexion of the distal joint
are limited when the middle joint is held in full
passive extension (see Diagnosis, p. 45).
Function of tendon plus scar. If the central
tendon rupture is not reduced promptly and held
until healed, the gap is bridged by scar. The
healed tendon unit plus the scar will be too long
functionally
to move the middle phalanx into
full extension. Maturation and gradual contracture of this scar may give some improvement in
function if supported by prolonged, adequate
splinting.
But recovery of a complete range of
active motion in the middle and distal joints has
not been observed in an established deformity of
more than 2 weeks’ duration,
except with operation.
The established
deformity. In the established deformity contracture of the transverse
fibers of the retinacular ligaments hold the displaced lateral bands below the axis of the joint.
This hinders late attempts to reposition
the
lateral bands by splinting alone. Contracture of
the oblique fibers of the retinacular ligament will
limit distal slide of the terminal extensor tendon.
These fibers may require specific release in selected cases in order to obtain flexion of the
terminal phalanx 36 (p. 47).
The fixed deformity. Joint damage by disease, traumatic dislocation,
or intra-articular
fracture may be irreversible.
Contracture of the
volar plate, capsular ligaments, or sublimis tendon may also fix the middle joint in flexion. It is
occasionally feasible to release these contractures
and convert the fixed deformity to a mobile deformity. 36
Etiology
The central band of the extensor mechanism
is poorly protected from injury in its superficial
position over the middle joint. The lateral bands
in tb:eir slightly more volar location may be
spared and will contribute to the development
of a boutonniere deformity.
The common injuries.
The three injuries
most frequently responsible for loss of continuity
of the central bands are laceration, crush of the
tendon against the head of the proximal phalanx,
and avulsion of the tendon at or near its insertion.
The latter injury is seen with sudden, forceful,
passive flexion of the actively extended finger as
in volleyball or baseball injuries. The frequency
of this type of injury accounts for the greatest
involvement of the longest digit,
the middle
finger. The relatively unprotected little finger
and the index finger follow in that order, while
the r ng finger is seldom involved as an isolate.d,.
~’’~:DeN~a ~uplure::@~ndons
weakened by a
previous injury may rupture several hours, days,
or even a week later in response to minor trauma.
Delayed rupture will be prevented only by the
proper diagnosis and treatment of the initial
injury. Gradual stretching of an injured tendon
and tearing of the triangular ligament will also
produce a late deformity.
Dislocations and fractures. The history of
a:n associated dislocation of the middle joint of
the finger is important in estimating the prognosis for recovery of function. The derangement
is mc.re than an extensor tendon injury and the
patient is less likely to recover a full range of
joint motion.
Avulsion of a small bone chip with the tendon
is seldom significant.
Large fragments and intraarticular fractures,
however, are more complex.
These special problems are best considered with
fractures of the hand.
~*
Burns and abrasions.
The central
tendoa
will usually be damaged by a third degree thermal or abrasion injury that destroys the skin
cover over the middle joint. If the lateral bands
are spared, a typical boutonniere deformity will’
Boutonnieredeformity
develop. Unfortunately, the joint is also damaged in somecases.
Rheumatoiddisease. A boutonniere deformity may accompanyrheumatoid arthritis of the
hand when the extensor apparatus is disrupted
1~ states that the
by invasive synovitis. Heywood
initial lesion attenuates the central band near its
insertion. Involvementof the triangular ligament
area then permits the lateral bands to separate
and migrate volarward to establish the typical
deformity. The stretching caused by effusion of
the middle joint will hasten the distortion of the
extensor mechanism.
Diagnosis
Initial confusion. In traumatic cases involving crush or avulsion, the initial swelling and
pain maybe quite severe and voluntary motion
restricted. This frequently leads to a significant
delay in determining the true diagnosis and obtaining proper treatment. It is certainly not
uncommonfor the surgeon to see this problem
for the first time more that 2 weeksafter injury.
There is usually no roentgenographic evidence
of fracture, and the finger has generally been pro~
tected on a volar splint in slight flexion. The
tentative diagnosis is a sprain. Whenfailure of
active extension of the middle joint finally be-comes evident, the true nature of the tendon
problem is suspected. Deformities caused by
simple lacerations of the central band and deformities due to rheumatoid disease are more
easily recognized.
Subsequent evaluation. In all cases, an
accurate history of the injury or disease is helpful. X-ray examination should be routine. In
traumatic cases there is usually somepersistent
tenderness and edema on the dorsum of the
middle joint. Perhaps even a tell-tale bruise or
repaired laceration over the head of the proximal
phalanxwill indicate the level of injury. There is
usually a full range of active flexion of the middle
and distal joints with a limited range of active
extension of the middle joint.¯
of the middle oint is
45
ret~rs t.o this intrinsic imbalanceas an !!intrinsic
intrlnStcp us. ::~.
" ...... ...... ~:
Latedeformities. There is seldom any &fficulty in diagnosis of a long-standing classic defor:mity aRer the edema and tenderness have
subsided. Other causes of flexion deformity of
the middle joint such as dorsal bone block, volar
capsule contracture, and derangement of the
flexor mechanismmust be ruled out by thorough
examination. A true boutonniere deformity will
have reciprocal extension of the proximal and
distal joints, t~
TREATMENT
Indications for surgery
The mere existence of the deformity does not
constitute an indication for treatment. Many
patients will experience fairly good function and
have a minimumof complaints.
Preblems, other than the acute injuries, that
bring patients for evaluation by the surgeon are,
in approximate order of frequency: appearance,
clumsiness, repeated injury to a prominent
knuckle, annoying tightness in the finger, and
stiffness of the distal joint.
These complaints must be evaluated in the
light of the patient’s age and motivation, the
etiology of the deformity, and the mobility of the
joints. A proper decision must then be based on
the probability of offering significant improvement of the patient’s specific complaints. A frank
discuss~on of treatment, length of disability, and
anticipated results will prepare the patient for the
cooperation and effort required to obtain the
best result.
Ac~ate tendon injuries
Principles. Prompt treatment of extensor
tendon injuries at the middle joint level will
usually restore good function and prevent progressive deformity. Fresh lacerations of tendon
are repaired with the middle joint splinted in
full extension. Closed tendon injuries, seen within 2 weeks, are treated simply by splinting.
Techniques of repair. Closed injuries are
usually treated by transarticular Kirschner wire
fixation of the middlejoint in full extension (Fig.
6-1). The wire is passed into the middle phalanx
in the midlateral plane and crosses the joint
obliquely to enter the proximal phalanx. The
end of the wire is always left protruding, capped
with cotton and collodion, to facilitate removal
46
Symposium on the hand
l~ig. 6-1. Acuteboutonnieredeformity.A, Closedavulsion injury. B, Middlejoint pinned in full extension.
(FromElliott, R. A.: Orthop.Clin. N. Amer.1:335-354,
Nov.1970.)
Fig. 6-2. Acuteboutonniere deformity. A, Laceration injury. B, Tendonrepair and middle joint fixed in full
extension. (FromElliott, R. A. : Orthop. Clin. N. Amer.
1:335-354, Nov.1970.)
in the office. The distal joint is free to exercise,
but only with additional manual support of the
middle .joint.
Occasionally a rigid safety-pin
splint will be used instead of the wire in a very
reliable patient. This splint supports the volar
surface of the proximal and middle phalanges as
the web strap is tightened over the dorsum of the
middle joint. The distal phalanx is left unsupported and active flexion of the distal joint is
encouraged.
When there-is
a laceration
of tendon, the
traumatic wound is extended with an undulating
incision to gain exposure and assure an accurate
repair. The middle joint is fixed with a Kirschner
wire before the tendon sutures are placed. A complete division of the central tendon is sutured
with a continuous 4-0 stainless steel pullout wire
(Fig. 6-2). Partial lacerations of the central band
and lacerations of the lateral bands, are repaired
with buried interrupted
5-0 sutures of nonabsorbable material. A rigid external splint is sufficient for some incomplete lacerations.
Postoperative care. Acute injuries are splinted for 7 weeks. The internal fixation is maintained for 5 weeks. A safety-pin splint is worn
continuously for an additional week, and then as
a night splint during the final week. After the
splinting is discontinued, active extension ex-
ercises of the middle joint are encouraged and
distal joint flexion is continued with manual support of the middle joint. Active flexion of the
middle joint is not specifically encouraged during
the first 2 months. After that time, active and
passive exercises at both joints will hasten improvement. In patients over 45 years of age,
internal splinting is held only 4 weeks and the
entire program is moved ahead 1 week.
Results. When treatment has been initiated
within 2 weeks of the injury and immobilization
has been effective
for the prescribed period,
essentially
normal function has been recovered.
The internal pin fixation has afforded the most
reliable immobilization of the middle joint in the
acute injuries, and the wire is tolerated very well.
Established
mobile deformities
Principles. Surgical reconstruction of the ex-.
tensor mechanismis indicated in selected cases of
established
deformity of more than two weeks
duration. If the joints are mobile, prolonged.
safety-pin splinting 5 ~,9
or ’1°
extensor tenotomy
will offer improved function, but the best results
are seen with an anatomic reconstruction of the
extensor mechanism.* Long-standing
deformi*Seereferences7, 8, 28, 33, and36.
Boutonnieredeformity
1
B
C
C1
Fig, 6-3. Correctionof establishedmobileboutonnieredeformity.A, Normal
anatomicrelationships. B, Deformity
with retracted central tendonandscar bridge, tear in triangular
ligamentarea, anddisplacementof lateral bandsbelowaxis of middlejoint. C, Anatomic
repair with fixation of middlejoint in full extension.(FromElliott, R. A. : Orthop.Clin.
N. Amer.1:335-354,Nov.1970.)
ties mayrequire weeks or months of preoperative
splinting to gain full passive motion. The surgery
is delayed at least until a maximumpassive
motion is obtained, because the final result will
seldom exceed the preoperative passive range of
motion.
Technique of repair.
The technique of
anatomic repair that I use is shownin Figs. 6-3
and 6-4. General anesthesia and tourniquet control are used, and the extensor mechanismis exposed through an undulating dorsal incision.
The transverse fibers of the retinacular ligament
are divided bilaterally and the lateral bands are
mobilized from the midportion of the proximal
phalanx to their junction beyond the triangular
ligament. The scar overlying the middle joint is
sectioned transversely at least 0.5 cm. proximal
to the normal insertion of the central band on
the base of the middle phalanx. The scar and
central .band are separated from the ,joint capsule
and reflected to about the midportion of the
proximal phalanx in an areolar plane deep to
the vascular mesotenon. 27 Good tendon excursion is demonstrable when this dissection is
sufficient.
The middlejoint is fixed in full extension with
a transarticular Kirschner wire, and the mobilized central band is advancedas far as possible
by fir:m traction on the attached scar. A portion
of the latter is serially amputatedas a scar-to-scar
anastomosis is completed with the cuff of scar
preserved on the middle phalanx. Interrupted
nonabsorbable sutures are used. The converging
lateral bands are approximated with two sutures
in the triangular ligament area and the central
tendon and scar are trimmed slightly on each
side to accommodatethese bands in their normal
position.
After the repair is completed, the surgeon
should test the range of passive flexion of the
distal joint to determine the need for release of
36
the Oblique fibers of the retinacular ligaments.
If a tenodesis effect is evident, the release is done
along the insertion on the sides of the lateral
band’s and terminal tendon.
The postoperative splinting and mobilization
programis the same as has been described for the
acute tendon injuries. Earlier passive exercise is
unwise, for the scar anastomosismaybe stretched.
In the established deformities, patience is a
virtue; tlhe recovery of a maximumrange of
motion may take 9 months.
Resul.ts. Since 1961 I have used this treatment plan in a series of twenty-five patients involving twenty-seven digits. The best results were
in patients with mobile deformities in whoma
Symposium on the hand
i~ig. 6-4. Anatomic repair of established mobile deformity. A~ Exposure through undulating
incision. Scar outlined over middle joint. B~Lateral bands mobilized proximal and distal to
middle joint. Note their spread and volar migration as comparedwith It. C, Scar transected
leaving a cuff of tissue on middle phalanx for the repair. II, Mobilization of scar and tendon
from dorsumof joint and proximal phalanx. E, Midclle joint fixed in full extension. Traction
on scar advances central tendon and relaxes lateral bands. F, Redundant scar excised and
scar-to-scar anastomosis completed. 13, Relocation of lateral bands by approximation in
triangular ligament area. I-I~ Mobilized lateral bands in anatomic position. I~ Central tendon
and scar narrowed to accommodatethe relocated lateral bands. J, Closure after excision
of redundant skin flap.
Boutonniere deformity
full range of passive motion of the middle joint
was obtained before surgery (Figs. 6-5 to 6-7).
There were fifteen patients,
ages 19 to 51
years, with posttraumatic deformities involving
fifteen fingers whomet this criterion of full preoperative mobility. Traumatic deformities of the
thumb and deformities of congenital or rheumatoid origin were excluded from this group, although the anatomic repair has given good
results in the small number of such cases treated.
In the thirteen determinant cases followed at
least 8 months, there were two failures related to
reinjury.
The recovery of active middle joint
extension was 180 degrees in nine patients and
165 degrees in two patients. Interestingly,
both
of the patients with less than full extension gave
a history of associated middle joint dislocation.
At the distal joint, active extension varied from
170 to 180 degrees. All patients gained good
flexion at both the middle (90 to 120 degrees)
and distal (40 to 65 degrees) joints.
There were no patients over the age of 51
years in whom a full range of passive motion
could be obtained before surgery. Most of the
older patients with symptoms were treated with
a siimp][e tenotomy.
Discussion. The preservation of a cuff of scar
attached to the base of the middle phalanx obviates the more complicated
bony attachments
described in the literature.
The utilization of a
portior.~ of the scar to prolong the central tendon
obviates the use of a tendon graft. The scar is
not likely to be stretched provided the immobilization program is followed as outlined. If the
scar is stretched by earlier passive flexion of the
middle joint, the tendon unit plus scar will again
becometoo long to actively extend the joint fully.
The good recovery of middle joint extension must
be attributed
in major part to the prolonged
postoperative splinting.
The recovery of distal joint motion depends
upon an effective
advancement of the lateral
bands. This is accomplished in the anatomic
repair by mobilization of the lateral bands and
l~ig. 6-~ ¢~at~d. For legend see oppositepage.
50
Symposium on the hand
advancement of the central band to which they
are attached. Release of the oblique fibers of the
retinacular ligament is considered only in those
patients in whomtenodesis of the lateral bands
persists after advancement of the central tendon.
A tenotomy of the terminal
tendon is never
needed.
Techniques of repair that do not advance the
lateral
bands may require tenotomy of these
bands to gain flexion at the distal joint. The
l~ig. 6-5. Established mobiledeformity in a 19-year-old
male. A~ Preoperative deformity 38 days after untreated
acute flexion injury. B~Active extension 35 monthsafter
anatomicrepair. (3, Activeflexion 35 monthspostoperatively.
l~ig. 6-6. Established mobiledeformity in a 41-year-old
man. A~Preoperative deformity 52 days after repair of
laceration (physiotherapy started at 3 weeks). B~Active
extension40 monthsafter anatomicrepair. (3~ Activeflexion
40 monthspostoperatively.
Boutonniere deformity
tenotomy must be done proximal to the preserved fibers of the oblique retinacular ligaments
to avoid a permanent flexion deformity at the
distal joint. In the absence of adhesions of the
terminal tendon to the distal half of the middle
phalanx or to the distal joint capsule, a combination of lateral
band tenotomy and release of
the oblique fibers of the retinacular ligament will
assure creation of a drop-finger deformity. The
continuity of one or the other must be preserved.
Deformities
with impaired passive
motion
Principles.
When full passive extension of
the middle joint cannot be obtained by preoperative splinting or release of contracted structures in the volar compartment, a full range of
motion cannot be restored by reconstruction
of
the extensor mechanism. If the flexion deformity
51
of the middlejoint is not severe, relief of the distal
joint hyperextension will improve comfort and
function. 6 The more acutely flexed deformities of
the middle joint, however, will require fusion in
a functional position. Fusion of the middle joint
is also indicated when grip and pinch are impaired by joint destruction or irreparable damage
to stabilizing ligaments.
’Techniques of repair. The anatomic repair
tha~: was described for correction of the mobile
deformities
is used for some deformities with
mildly impaired passive extension. The middle
joint is fixed in maximumextension and the rehabilitation
program is the same as for the fully
mobile deformities.
9The simple tenotomy introduced by Fowler
is usually effective for relief of distal joint hyperextension.
The operation is done with local
Fig. 6-7. Established boutonnieredeformity in a 51-year-old manwith full range of passive
middlejoint motion.A, Preoperativedeformity8 monthsafter injury. Initial repair had been
held in full extension for only 2 weeks"becauseof his age." Active and passive flexion were
followed by recurrence of the deformity. B, Twoweeksafter secondary anatomic repair.
Middlejoint pinnedin full extension(4 weeks).C, Active extension4 monthspostoperatively.
D, Active flexion at 4 months. (FromElliott, R. A.: Orthop. Clin. N. Amer.1:335-354,
Nov.1970.)
52
Symposium on the hand
anesthesia
and it can be an ambulatory pro-.
cedure.
Fusion of the middle joint is done through a
dorsal incision. The joint is entered by detachment of the central extensor band. The lateral
bands are carefully preserved. The cartilagenous
joint surfaces are removed at the proper angle
with a small power saw. The bone is sacrificed
sparingly to avoid carrying the resection beyond
the bulbous portions.
This assures maximum
apposition and surer union. Severe soft tissue
contractures may require a wider resection of the
joint,
however, to relax the contractures
and
permit fusion in the desired position. A single
Kirschner wire is used for immobilization,
as
crossed wires tend to distract the bones during
the period of normal resorption.
The wire is
passed retrograde through the resected end of
the middle phalanx and then advanced across
the reduced bone ends into the proximal phalanx.
The end of the wire remains protruding from the
side of the middle phalanx to facilitate
its re..
moval in the office.
llesults. The anatomic repair will usually re..
store an active range of extension that equals the
preoperative range of limited passive motion. As
with the mobile deformities, one can expect good
results in the younger patients. However, three
reconstructions have been done for patients over
the age of 60 and all three regained active extension equal to the range of preoperative passive
motion.
Tenotomy has given good relief of symptoms
and some improvement of function in most patients. An example of a desireable result is shown
in Fig. 6-8.
Fig. 6-11. Establishedboutonnieredeformltywi~:h
limlted middlejoint mobilityin a 57-year-old
laborer. A~Maximum
range of active and passive extensionafter 6 weeksof splinting. B~Active
flexion preoperatively. C~Active and passive extension8 monthsafter conjoinedlateral band
tenotomy.I), Rangeof flexion 8 monthsafter tenotomy.(FromElliott, R. A.: Orthop.Clin.
N. Amer.1:335:354, Nov.1970.)
Boutonniere deformity
Fusion of the middle joint is not difficult and
failure is unusual. Good function depends upon
a stable fusion in the best position for the particular digit. The radial two fingers are usually
fused in more extension than the ulnar two fingers, but this mayvary with the patient’s desires.
Fig. 6-9. Fixedboutonnieredeformityin a 19-year-oldmale.
A, Burndestruction of central tendon at the middlejoint
level withtenodesisof distal joint. B, Extensionafter middle
joint fusion and conjoined lateral band tenotomy.C, Range
of postoperative flexion. (FromElliott, R. A.: Orthop.
Clin. N. Amer.1:335-354, Nov.1970.)
53
Burns and abrasions
When third degree thermal and abrasion
injuries destroy the skin cover over the middle
joint, early repair is mandatory to protect the
tendon and joint from progressive
damage.
Prompt wound excision
and immediate skin
grafting has saved some tendons. The healing of
granulating
wounds should be hastened with a
thin skin graft.
Reconstruction with a flap of skin and fat is
required when bare tendon is exposed or a tendon graft repair 26,~°,~ is planned. The application of a flap must be reserved for healed wounds
or clean surgical defects. Flaps have no place in
the early treatment of burn defects but may be
used in fresh abrasion injuries if a clean surgical
defect can be created.
Arthrodesis of the middle joint, with some
shortening of the finger, is useful for flexion contractures after burns of the dorsal capsule (Fig.
6-9). Attempts to restore motion in these cases
are complicated and seldom successful.
Arthrodesis of the distal joint in stight flexion
is advised for hyperextension deformities that
cannot be relieved by tenotomy of the lateral
bands. A simple tenotomy will not be effective if
the terminal tendon is adherent to the capsule
of the distal joint or if the dorsal skin is scarred
and contracted.
Rheumatoid deformities
Much that has already been discussed will apply to the correction of rheumatoid deformities, but there are some peculiarities.
Mobile
deti~rm.itieS ~ can be treated with the anatomic
repair that has already been described, provided
that there is a full range of passive extension and
minimum joint damage as seen by x-ray evaluation. The number of cases is still too small for
analysis, but the preliminary results have been
very encouraging.
Heywood~ recently reported
very good results with a similar procedure for
correction of the mobile deformities. He advances
the central tendon and crosses one lateral band
in the triangular ligament area to prevent volar
migration of the bands. The crossover is obviated
in the anatomic repair by simple approximation of the mobilized bands with two sutures.
Deformities with impaired passive motion are
treated with tenotomy or arthrodesis.
Arthrodesis is preferred for sharp flexion contractures
and for patients with advanced joint destruction.
Symposium on the hand
A stable fusion is more difficult
to obtain in the
rheumatoid deformity.
Granowitz and Vainio, ll
reporting
on a series of 122 cases, indicate
some
advantage
in the use of two crossed Kirschner
wires for immobilization.
They also suggest inserting the proximal phalanx into the base of the
middle phalanx when the head of the proximal
phalanx has been destroyed.
REFERENCES
1. Backhouse, K. M., and Catton, W.T. : An experimental
study of the functions of the lumbrical muscles in the
humanhand, J. Anat. 118:133, 1954.
2. Bingham, D. L. C., and Jack, E. A.: Buttonholed extensor expansion, Brit. Med.J. 2:701, 1937.
3. Bunnell, S.: Surgery of the hand, ed. I, Philadelphia,
1944, J. B. Lippincott Co.
4. Bunnell, S.: Intrinsic muscles of fingers. Bunnell, S.:
Surgery of the hand, ed. 4 (revised by J. H. Boyes),
Philadelphia, 1964, J. B. Lipplncott Co.
5. Bunnell, S.: Rupture of tendons. In Bunnell, S.:
Surgery of the hand, ed. 4 (revised by J. H. Boyes),
Philadelphia, 1964, J. B. Lippincott Co.
6. Dolphin, J. A.: Extensor tenotomy for boutonniere deformity of the finger, Proceedings of the Americansociety for surgery of the hand, J. BoneJoint Surg. 45A:
878, 1963.
7. Elliott, R. A.: Extensor tendon injuries at the interphalangeal joint levels. Presented to the AmericanSociety for Surgery of the Hand Meeting, Chicago, Jan.
1965.
8. Elliott, R. A.: Injuries to the extensor mechanismof
the hand, Ortho. Clin. N. Amer. 1:335, Nov. 1970.
9. Fowler, S. B. : Extensor apparatus of the digits, J. Bone
Joint Surg. 31B:477, 1949.
I0. Goldner, J. L.: Deformities of the hand incidental to
pathological changes of the extensor and intrinsic
muscle mechanisms,J. Bone Joint Surg. 35A: 115, 1953.
1 I. Granowitz, S., and Vainio, K.: Proximal interphalangeal joint arthrodesis in rheumatoid arthritis, Acta
Orthop. Scand. 37:301, 1966.
12. Hauck, G.: Die Ruptur der Dorsalaponeurose
am
ersten Interphalangealgelenk, zugleich ein Beitrag zur
Anatomic und Physiologic der Dorsalaponeurose, Arch.
klin. chir. 123:197, 1923.
13. Heywood, A. W. B.: Correction of the rheumatoid
boutonniere deformity, J. Bone Joint Surg. 51A:1309,
1969.
14. Kaplan, E. B.: Extensor deformities of proximal interphalangeal joints of fingers, J. BoneJoint Surg. 18:781,
1936.
15. Kaplan, E. B.: Pathology and operative correction of
finger deformities due to injuries and contractures of
the extensor digitorum tendon, Surgery 6:35, 1939.
16. Kaplan, E. B.: Functional and surgical anatomy of the
hand, ed. 2, Philadelphia, 1965, J B. Lippincott Co.
17. Kilgore, E. S., Jr., and Graham,W.P., III: Operative
treatment of boutonniere deformity, Surgery 64:999,
1968.
18. Landsmeer, J. M. F.: Anatomyof the dorsal aponeu..
rosis of the humanfinger, and its functional significance, Anat. Rec. 104:35, 1949.
19. Littler, J. W., and Eaton, R. G.: Redistribution of
forces in the correction of the boutonniere deformity,
J. Bone Joint Surg. 49A:1267, 1967.
20. Mason, M. L.: Rupture of tendons of the hand, Surg.
Gynec. Obstet. 50:611, 1930.
21. Matev, I.: Transposition of the lateral slips of the
aponeurosis in treatment of longstanding "boutonniere
deformity" of the fingers, Brit. J. Plast. Surg. 17:281,
1964.
22. Milch, H.: Buttonhole rupture of the extensor tendon
of the finger, Amer.J. Surg. 13:244, 1931.
23. Milford, L. W., Jr. : Retaining ligaments of the digits
of the hand, Philadelphia, 1968, W. B. Saunders Co.
24. Montant, R., and Baumann, A.: Anatomical research
in the system of the extensor tendons of the fingers,
Ann. d’Anat. Path. 14:311, 1937.
25. Montant, R., and Baumann, A.: Rupture luxation of
the extensor apparatus of the fingers of the first interphalangeal articulation, Rev. d’Orthop. 25:5, 1938.
26. Nichols, H. M.: Repair of extensor tendon insertion in
fingers, J. Bone Joint Surg. 33A:836,1951.
27. Smith, J. W.: Tendon injuries. In Grabb, W. C., and
Smith, J. W., editors: Plastic surgery, Boston, 1968,
Little, Brownand Co.
:_78.Smith, R. J. : Boutonniere deformity of the fingers,
Bull. Hosp. Joint Dis. 27:27, 1966.
’29. Stack, H. G. : Muscle function in the fingers, J. Bone
Joint Surg. 44B:899, 1962.
30. Tubiana, R.: Surgical repair of the extensor apparatus
of the fingers, Surg. Clin. N. Amer.48:1021, 1968.
31. Tubiana, R., and Valentin, P.: The anatomy of the
extensor apparatus of the fingers, Surg. Clin. N. Amer.
44:897, 1964.
32. Tubiana, R., and Valentln, P.: The physiology of the
extension of the fingers, Surg. Clin. N. Amer.44:907,
1964.
33. Verdan, C. E.: Repair of tendons. In Flynn, J. E.,
editor: Hand surgery, Baltimore, 1966, The Williams
& Wilkins Co.
34. Weeks, P. M.: The chronic boutonniere deformity: A
methodof repair, Plast. Reconstr. Surg. 40:248, 1967.
35. Weitbrecht, J.: Syndesmologia sive historia ligamentorum corporis humani, quam secundum observationes
anatomicas concinnavit, et figuric and objecta recentia
adumbratic illustravit.
Petropoli,
ex typographia
Academiae Scientiarum Anno 1742.
3(;. Zancolli, E.: Structural and dynamic bases of hand
surgery, Philadelphia, 1968, J. B. Lippincott Co.
Discussion
Dr. Chase: I also would like to select only very
cooperative patients under the age of 45 for
all surgery, if possible.
Dr. Zancolli: Speaking of results of treatment of
the boutonniere deformity, I think it is very
important to know the exact pathology of the
deformity, because the results of treatment
are contingent upon this pathology. I believe
that the operation that Dr. Elliott presented
works. We have been doing the same operation for at least the last 15 years. This operation gives excellent results only under certain
circumstances, however.
In the evolution of the deformity, there
are three different periods. Initially,
even
with the rupture of the central tendon and
the dislocation
of the lateral
tendon, the
longitudinal or oblique portion of the retinacular ligament is relaxed,
because the
distance between its origin and insertion is
shortened. To demonstrate the oblique retinacular ligament laxity in this period of
deformity, it is still possible both to extend
the middle joint and to flex the distal joint,
because the retinacular ligament is relaxed.
Later, in the second period of the deformity,
the retinacular ligament retracts because now
this has been filled with scar tissue.
Now the retinacular
test shows that the
PIP joint extension does not allow the distal
joint to flex. Not only is it impossible to flex,
but it also has increased tension. If we employed the operation Dr. Elliott showed in
this case, failure is going to result. It is impossible to obtain a good result in this condition with that operation unless, when we
finish the operation,
we can have partial
flexion of the joint. I feel we must release the
deformity, and then reconstruct the extensor
apparatus. The release of the deformity is
accomplished by dividing the interossei and
the rel:inacular
ligaments. Wedon’t see the
longitudinal part of the retinacular ligament
during the operation. But we know that if we
dissect the most lateral fibers of the lateral
extensor tendon, we have done the releasing
of the original ailment. If we do these first
and then obtain flexion of the joint, and then
advance this and relocate the extensor tendon, we will have a good result
in this
retinacular stiffness.
In the third period, things are more complicated because we see that not only is the
retinacular ligament tight, but also there is
a retraction of the volar plate. We have retraction of the retinacular ligament, and this
is not only ligamentous stiffness, it is articular
stiffness. In this case it is very difficult to
obtain a good result, even with the retinacular release.
If you want to try treatment at this stage,
the operation is very complicated, but it is
possible to try it. The first step is the release
of the retinacular ligament, of course on both
sides. This is very important. Then a capsulecmmy is done, supplemented by a release
of the proximal part of the volar plate.
Dr. Chase: These additional points I think are
terribly important and I am sure Dr. Elliott
will want to address himself to them.
Dr. Little:r:
I have great respect for Dr. Zancolli’s analysis of this problem, because I have
run inl:o problems in a rather similar fashion.
It seems very important, as he points out, to
direct the displaced forces dorsally so the
extensor and the intrinsic
mechanisms, which
are acting in the deformity as flexors of the
joint, are converted to be just extensors. It
seems to me that, although the oblique retinacular ligament does tighten with time, if
the extensor forces are directed dorsally to
correct the displacement,
and the oblique
retinacular ligament is relieved bilaterally so
that the tip doesn’t drop, quite often extension of the PIP joint can be regained--pro55
56
Symposium on the hand
vided, of course, that the lower fibers of the
collateral
ligaments and the volar plate are
not irretrievably contracted.
The oblique retinacular
ligament is the
only thing left--unless
you leave the lumbrical--to extend the terminal phalanx. If you
can, in directing the displaced extensor forces
to the dorsum of the finger, gain extensio:n
within the passive range, as the PIP joint
extended, it will tighten the oblique retinacular ligament. The terminal phalanx will be
dynamically tenodesed and extended automatically. Then, with flexion of the PIP joint,
the oblique retinacular ligament is released[,
and finger flexion is possible.
This is a tricky mechanism, and I don’t
believe that there is a simple answer to solve
the problem, but you do try to correct, insofar as is possible, the pathologic condition,
restoring it so that at least all the extensor
forces which have been displaced are now
acting on the dorsum of the PIP joint.
Dr. Boyes: In this illustration
that Dr. Zancolli
made showing the hyperextension of the distal joint, when you bring the middle joint up
in restoring the position, we call this the
"intrinsic
intrinsic
plus" finger. In other
words, it is the same idea as testing for the
intrinsic tightness of the interossei. You extend the metacarpophalangeal
joint and the
middle joint stays in extension.
Most surgery for the boutonniere de.formity is a complete waste of your time and
effort. The expense to the patient and the use
of the hospital beds, which could be occupied
by other patients on whomI would rather do
some surgery, are also bothersome. I think
most can be treated by splinting. If the splint..
ing is applied properly, you can do it as late
as 30 days after the injury, the idea being to
splint the middle joint only, in full extension,
and not to splint the distal joint. The distal
joint must remain free. You leave the splint:
on for a minimum of 5 weeks--long enough
so that with the middle joint in extension on
the splint, the patient can voluntarily flex
the distal joint to the same degree as on his
opposite normal finger.
The retinacular
ligament,which has been
shortened, has relengthened and stretched
out. Five weeks is enough time for the scar
tissue to heal. The results are extremely good,
in spite of the fact 1hat we don’t select only
the 4 l-year-olds and the cooperative patients.
Dr. Chase: I think that is a very important point.
One thing the scar tissue does is to contract,
if given the opportunity. Since this is one of
the circumstances in which it can do so, I
think the boutonniere has to be pretty much
a fixed deformity before one would operate
on it.
Dr. Tupper: There is one additional injury that
masquerades as the classical boutonniere deformity. This is a closed injury on each of th.e
three cases I have explored. I wonder how
many have been missed. The usual pathology
shows that the central slip is completely intact
across the dorsum, the lateral band has split
across the condyle of the proximal phalanx,
and the collateral
ligament has ruptured
allowing the lateral
band to become incarcerated in the intercondylar notch. If a little
xylocaine is put into this joint and stress films
are taken, one can pick up this particular
variation of the injury on x-ray, but not on
routine films.
To treat these three patients I have rereduced the lateral band, brought it up and
sutured it to the main tendon with a running
suture. I have not dealt with the collateral
ligament except to put it in place. Although
it has been a stable affair after the lateral
band has come up, all three of them have
had bad results.
Dr. Elliott:
I find agreement with most of Dr.
Zancolli’s discussion and this basic agreement
will be more evident with review of my full
manuscript. Release of the contracted oblique
retinacular ligaments is indicated only when
these ligaments exercise a tenodesis effect on
the lateral bands, preventing their advancement and thus limiting flexion of the distal
joint. But this can be tested for after completion of the anatomic repair, and the release
is simply added when needed.
Dr. Littler’s operation for redistribution
of the extensor forces requires section of both
lateral bands. If section of the oblique retinacular ligaments is added to this operation,
a drop finger deformity will occur at the
distal joint.
It must be emphasized that, in any given
method of repair, either the lateral bands or
the oblique retinacular
ligaments must be
left intact to avoid a drop finger deformity of
the distal joint. In the anatomic repair it is
usual to preserve both.
Volumethree
Symposium on the.
hand
Editors
LESTERM. CRAM[ER,D.M.D., M.D., F.A.C.S.
Professorand Chairman,
Section of Plastic Surgery,
TempleUniversity HealthSciences Center,
Philadelphia,Pennsylvania
ROBERTA. CHASE, M.D., F.A.C.S.
Professorand Executive, Departmentof Surgery,
Stanford University MedicalCenter,
PaloAlto, California
Proceedings of the Symposiumof the Educational
Foundation of the American Society of Plastic and
Reconstructive Surgeons, Inc., held at Stanford University,
March 25, 26, and 27, 1970
With 499 illustrations
The C. V. MosbyCompany
Saint Louis 1971