- Discussion:
- soft tissue procedures will work only passive ROM is re-established;
- Staged Method of Treatment: (from Raymond et al 1982)
- use a metacarpal block for anesthesia (for intial three stages);
-
stage I and II:
- lazy "S" incision over the PIP joint;
-
lateral bands are freed from their attachments to
transverse retinacular ligament;
- extensor tenolysis is performed over the proximal phalanx and over
the PIP (freeing the tendon from the capsule);
- at this point re-assess ability to extend the PIP joint;
-
stage III:
- modified lateral band tenotomy (see below);
- Extensor Tenotomy:
- may be indicated for both rheumatoid and traumatic hyperextension DIP deformities;
- is especially indicated when the skin over the PIP is abnormal or scarred;
- is simple and is carried out to allow flexion of the DIP joint;
- this takes the tension off the proximal joint to some extent and can be effective in
correcting the deformity of the PIP Joint as well as the deformity at the DIP joint;
- tenotomy of the extensor tendon is performed distal to the triangular ligament
but proximal to the DIP joint (and proximal to the
ORL insertion, in order to
allow the ORL to maitain some DIP extension);
- alternative is to step cut the lateral bands over the middle phalanx and to then
suture the proximal and distal portions of the lengthened tendons;
- this method re-establishes the balance with the lengthened central slip,
while avoiding the complication of a mallet deformity;
- the DIP is then manipulated into hyperflexion to break up adhesions;
- postoperative dynamic splinting is directed at bringing the PIP joint into extension;
- mallet deformity should not develop as long as the
oblique retinacular ligaments;
- if postoperative mallet deformity is noted, then postoperative splinting
should correct the problem;
-
ref:
- Redistribution of forces in the correction of the Boutonniere deformity.
Littler JW, Eaton RG.
JBJS 49-A: 1267-74, 1967.
- Extensor Tenotomy for Chronic Boutonniere Deformity of the Finger.
Dolphin JA.
JBJS 47-A p 161-164, 1965.
- Extensor Tenotomy: A technique for correction of post-traumatic DIP
joint hyperextension deformity.
Stern PJ MD
J. Hand Surg. Vol. 14-A, No 3, p 546. May 1989.
- Lateral Bands:
- release or reconstruction
lateral bands;
- triangular ligament and
transverse retinacular ligaments are excised,
which allows the lateral bands to be repositioned dorsally;
- the bands are then sutured distal to the PIP joint;
- disadvantages: this procedure does not permit optimal tension and
excursion of the tendon to be extablished;
-
Salvi Technique:
- requires good passive ROM;
-
transverse retinacular ligaments are freed from palmar plate & then
transferred dorsally and are sutured together over the PIP joint;
- this technique helps to lift the lateral bands out of their volar position
but not rigidly fix them in a dorsal position;
- oblique or step cut tenotomy of
lateral bands distal to central slip insertion over
proximal metaphysis of middle phalanx (Dolphin, Fowler, or Nalebuff);
- dorsal transposition and suture of lateral bands (Littler);
- transposition of lateral bands to central slip (Matev & Littler);
- lateral bands are divided at different levels;
- the shorter proximal stump is sutured to the central slip;
- the longer proximal stump is sutured to the contralateral long distal stump;
- Method of Urbaniak and Hayes:
- curvilinear incision is made over the PIP;
- lateral bands are freed from transverse retinacular ligaments;
- a proximally based triangular flap is created between the lateral bands;
- the flap is elevated off the joint capsule, and is reflected proximally;
- a second distally based flap is made off the capsule of the PIP joint;
- the second flap is passed proximally thru a rent made in the first flap;
- the lateral bands are opposed over the middle phalanx;
- they may be sutured more proximal as long as full passive flexion of
the DIP joint is maintained;
- the distally based flap is sutured to the central slip;
- the proximally based flap is sutured over the dorsally positioned lateral bands;
- a K wire holds the joint in full extension;
----------------------------------------
Chronic boutonniere deformity--an anatomic reconstruction.
The management of chronic posttraumatic boutonniere deformity.
Surgical repair of the boutonniere deformity of the fingers.
Correction of the severe nonrheumatoid chronic boutonniere deformity with
a modified Matev procedure.
Biomechanical evaluation of chronic boutonniere reconstructions.
Tendon reconstruction for postburn boutonniere deformity.
Year Book: Operative Treatment of the Post-Traumatic Boutonniere
Deformity: A Modification of the Direct Anatomical Repair Technique.
Caroli-A.
Zanasi-S.
Squarzina-PB.
Guerra-M.
Pancaldi-G.
1992 Year Book of Hand Surgery. Article 6-10.
Original Article: J Hand Surg. 1990. 15-B. pp 410-415.
Year Book: Operative Treatment of the Post-Traumatic Boutonniere Deformity:
A Modification of the Direct Anatomical Repair Technique.
A Staged Technique for the Repair of the Traumatic Boutonniere Deformity.
RM Curtis MD, RL Reid MD, and JM Provost MD.
Journal of Hand Surgery 8: 167-171, 1983.
