Rheumatoid Boutonniere


- See:
      - Boutonniere Injuries - Menu
      - Thumb Boutonniere Deformity

- Discussion:
    - rheumatoid boutonniere deformity begins w/ PIP synovitis & elongation capsule;
    - inflammation leads to lengthening of central extensor slip and triangular ligament (becoming dysfunctional) and volar displacement of the lateral bands (which leads to subsequent contracture of transverse retinacular fibers);
    - later there is attenutation of central slip & triangular ligament to allow volar subluxation of lateral bands;
            - lateral bands then become flexors of PIP joint;

- Stage 1:
    - 10-15 deg flexion deformity & extensor lag of PIP joint is passively correctable;
    - as PIP joint deformity is corrected, limited flexion of DIP will be noted;
    - consider dynamic splinting, & lateral band reconstruction (relocation dorsal to axis of rotation);
    - consider terminal extensor tendon tenotomy to improve DIP flexion;
            - this procedure is based on idea that oblique retinacular ligament acts to extend the DIP joint;

- Stage 2:
    - moderate deformity (PIP flexion deformity 30-40 degrees, flexible joint, preservation of joint space on X-ray);
    - pts w/ this deformity may compensate w/ MCP joint hyperextension;
    - terminal extensor tendon tenotomy to allow DIP flexion;
    - consider synovectomy;
    - central slip reconstruction and shortening;
    - lateral band reconstruction w/ release of transverse retinacular ligament;
    - postoperatively, PIP is held in extension w/ a K wire for 3 weeks;

- Stage 3:
    - fixed deformity w/ retinacular ligament tightness;
    - contracture and tightness of ORL and TRL;
    - deformity:
           - ORL: maintains DIP extension, blocks flexion;
           - TRL: maintains volar subluxation of lateral bands, PIP flexion
    - these patients may or may not feel that they have a functional deficit;
           - be careful to replace a functional flexion contracture with a poorly functioning stiff extended finger;
    - treatment spinting to restore PIP to full passive extension (may require serial casting);
           - active and passive ORL stretching, proceed as in stage II when the PIP is fully extended;
           - no reconstructive procedures should be tried, until passive ROM is restored;
    - if there is loss of articular cartilage, consider fusion for this deformity;

- Arthoplasty;
    - indicated for painful & stiff joint w/ x-ray evidence of joint destruction;
    - for deformities of more ulnar PIP joints;
    - PIP joint of the index finger does better w/ fusion in 20 to 40 deg flexion;
          - more stable index finger can be used in pinch and the more flexible middle finger can be used in grasp


Reference

Surgical treatment of the boutonniere deformity in rheumatoid arthritis.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, September 24, 2012 12:11 pm