Chapter 6 Boutonniere deformity

Ray A. Elliott, Jr., M.D.

A flexion deformity of the proximal inter.- but I would be remiss if I failed to acknowledge phalangeal (middle) joint with extension the background and experience gained from Dr’. hyperextension of the metacarpophalangeal Boyes~ during the latter half of 1959. Although (proximal) and distal interphalangeal (distal). he favors splinting rather than surgery for most joints in the absence of a bone block or de.~ange.. cases, the anatomic repair which he advocates ment of the flexor mechanism has long been con-. for a "long standing deformity in a young per- sidered pathognomonic of thd buttonhole or son" is the same repair technique that I have boutonniere deformity of the . used .since 1961 for the correction of the estab- One of the earliest descriptions of the button-. lished mobile deformity of more than 2 weeks’ hole deformity of the extensor mechanism was duration. This technique has been used in pa- detailed by Gustav Hauck12 in 1923. Using tients up to 51 years of age. Perhaps we vary only models and cadaver specimens he demonstrated. in our definitions of "long-standing" and the anatomy and pathologic physiology of this "young." intriguing entity. The more recent studies of I hope that this presentation will renew in- Kaplan, 14"16 Bingham and Jack, 2 Montant and terest in early operative management of selected Baumann, e4,2~ Bunnell, ~’~ Landsmeer, 18 Stack,2~ cases. The techniques to be presented here are Tubiana and Valentin, ~1,32 Milford, ~ and Zan- essentially unchanged from those I presented to colli ~6 have added greatly to our understanding. the American Society for Surgery of the Hand Of these major contributions, the clear descrip- in 1965.7 tions of the retinacular system of ligaments by Landsmeer and by Milford have been outstand- BASIC CONSIDERATIONS ing. We are now in a much better position to Essentials of anatomy understand and explain the mechanism of the The exhaustive studies of the men named in deformity and to have some explanation for the the opening paragraphs may be referred to for apparent success of various methods of treatment the minute details of anatomy and physiology of and the failure of others. Kaplan credits Weir- the extensor mechanism of the . To under-. brecht (1742) with the first description of these stand the buttonhole deformity, however, the important ligaments. surgeon must appreciate certain structures and Among the earliest treatment methods were fundamental relationships from these writings. the reports of Masone° (1930) and Milche~ (1931), The central band. The central band of the who both advocated prompt operation with re- extensor hood of the finger is a continuation of pair of the buttonhole defect in the central slip. the extensor communis tendon beyond its vari-. Mason also approximated the lateral bands in able insertion ~ on the proximal end of the prox- the midline, a technique followed later by imal phalanx. The majority of the central tendon Kaplan, 14 Montant and Baumann,2~ and others. fibers end in the distal part of the middle joint This symposium faculty was charged with pre- capsule with a bony insertion on the base of the sentation of their own methods of management middle phalanx. 1~ rather than discussing the methods of others, The lateral bands. The lateral bands ex- 42 . Boutonnieredeformity 43 change components with the central band but with little effect on the middle and distal joints. are predominantly the tendinous extensions of With the hood in the proximal position and the the lumbrical and interosseous muscles. They proximal joint stabilized in extension, the inter- unite distal to the middle joint at the triangular ossei can act through the lateral bands to extend ligament area and form a terminal extensor ten- the middle and distal phalanges. don, which blends with the capsule of the distal Function of lumbrlcals. The lumbrical mus- joint and inserts on the base .of the distal phalanx. cles¢ like the interossei, are flexors of the proximal The extensor expansion. The tendinous phalanx. In contrast, however, they are effective componentsof the extensor mechanismare joined extertsors of the middle and distal phalanges by an aponeurotic expansion, and together they regardless of the position of the proximal joint. 1 form the extensor hood. Although the hood may If the lumbricals and interossei exert their force move as one unit, the freedom of independent to hold the proximal joint in flexion, the common action of the componentssuggests some elasticity extensor tendon is free to exert its maximum 29 effect; through the aponeurosis to extend the of the tissue between them. ~ The retinacular ligaments. The retinacular two distal joints. ligaments emphasized by Landsmeer,is which Lateral band shift. The two lateral bands, often bear his name, arise from the proximal whiclh normally lie dorsal to the axis of motion phalanx and flexor tendon sheath in the volar of the middle joint, shift volarward wheneverthe compartment. The transverse fibers pass through middle joint flexes. The intact triangular liga- a windowin Cleland’s ligament at the level of me.m: limits the extent of the shift and prevents the~3 middle joint to insert on the lateral bands. tlhese bands from becomingflexors of the middle The deeper and more tendinous oblique fibers joint. This volar shift permits flexion of the distal have a broad insertion on the side of the lateral joint~ during active flexion of the middle joint. bands from the level of the middle joint to the Function of retinacular ligaments. The midportion of the middle phalanx. 31 These ele- transverse fibers of the retinacular ligament pro- ments are referred to as the transverse and duce the traction force for the volar shift of the ~ oblique retinacular ligaments to denote their lateral bands during flexion of the middle joint. anatomic and physiologic differences. These same fibers prevent the lateral bands from slipping toward the midline during extension of Essentials of physiology the middle joint. Thet~ excellent motion studies of Hauck, The oblique fibers of the retinacular ligament Bunnell, ~ Landsmeer,18 Stack, ~7 Tubiana and exert their pull on the distal phalanx through Valentin, ~ and Zancolli, ~6 and the electromyo- their insertion on the conjoined lateral bands. graphic studies of Backhouseand Catton t should Functionally these fibers lie volar to the axis of be reviewed for their detail. The surgeon inter- ~notion of the middle joint and dorsal to the axis ested in the treatment of the boutonniere de- of motionof the distal joint. Active flexion of the formity must understand a certain minimumof distal joint tenses the oblique fibers and tends to these dynamic actions. pull the middle joint into flexion. With both Function of commonextensor. The primary interphalangeal joints in the flexed position, action of the extensor communistendon is exten- passive extension of the middle joint tenses the sion of the proximal phalanx. However, with the obliclue fibers and tends to extend the distal proximal joint in extension or flexion and hyper- joint.~ extension blocked, this tendon can also extend Tendon healing. Tendons severed in para- the middle and distal phalanges.~6 If the prox- tenon do not separate widely. The ends prolif- imal joint hyperextends, as in the claw deformity erate: actively in search of each other--sometimes of ulnar palsy, the long extensor tendon is unable bridging the gap successfully with scar, but more to extend the distal two phalanges against nor- often becoming adherent to all surrounding mal~ flexor tone. structures. Function of interossei. Normally, the exten- EVALUATION OF THE DEFORMITY sor hood is free to slide proximally and distally Pathologic physiology with extension and flexion of the proximal joint. With the hood in the distal position, the inter- C, reating the deformity. Whencontinuity of ossei contribute to flexion of~the proximal joint the central extensor tendon is interrupted at the 44 Symposium on the hand level of the middle joint, the middle phalanx is and convert the fixed deformity to a mobile de- pulled into flexion by the strong sublimis flexor formity. 36 tendon. The head of the proximal phalanx may herniate through the tendon defect between the Etiology intact lateral bands, much as a button passes The central band of the extensor mechanism through a buttonhole. is poorly protected from injury in its superficial Initially, or soon after injury, the triangular position over the middle joint. The lateral bands ligament splits longitudinally, permitting the in tb:eir slightly more volar location may be lateral bands to spread apart and shift volar- spared and will contribute to the development ward. 25 When they slip below the axis of motion of a boutonniere deformity. of the middle joint they become flexors. Efforts The common injuries. The three injuries to extend the finger increase the tension on the most frequently responsible for loss of continuity lateral bands, producing flexion of the middle of the central bands are laceration, crush of the joint and extension or hyperextension of the distal tendon against the head of the proximal phalanx, joint. Tension on the lateral bands is also in- and avulsion of the tendon at or near its insertion. creased by the proximal retraction of the divided The latter injury is seen with sudden, forceful, or stretched central tendon, further aggravating passive flexion of the actively extended finger as the deformity. Active flexion of the distal joint is in volleyball or baseball injuries. The frequency difficult in the face of this increased tension and of this type of injury accounts for the greatest both active and passive flexion of the distal joint involvement of the longest digit, the middle are limited when the middle joint is held in full finger. The relatively unprotected little finger passive extension (see Diagnosis, p. 45). and the index finger follow in that order, while Function of tendon plus scar. If the central the r ng finger is seldom involved as an isolate.d,. 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 contrac- ~’’~:DeN~a ~uplure::@~ndons weakened by a ture of this scar may give some improvement in previous injury may rupture several hours, days, function if supported by prolonged, adequate or even a week later in response to minor trauma. splinting. But recovery of a complete range of Delayed rupture will be prevented only by the active motion in the middle and distal joints has proper diagnosis and treatment of the initial not been observed in an established deformity of injury. Gradual stretching of an injured tendon more than 2 weeks’ duration, except with op- and tearing of the triangular ligament will also eration. produce a late deformity. The established deformity. In the estab- Dislocations and fractures. The history of lished deformity of the transverse a:n associated dislocation of the middle joint of fibers of the retinacular ligaments hold the dis- the finger is important in estimating the prog- placed lateral bands below the axis of the joint. nosis for recovery of function. The derangement This hinders late attempts to reposition the is mc.re than an extensor tendon injury and the lateral bands by splinting alone. Contracture of patient is less likely to recover a full range of the oblique fibers of the retinacular ligament will joint motion. limit distal slide of the terminal extensor tendon. Avulsion of a small bone chip with the tendon These fibers may require specific release in se- is seldom significant. Large fragments and intra- lected cases in order to obtain flexion of the articular fractures, however, are more complex. terminal phalanx36 (p. 47). These special problems are best considered with The fixed deformity. Joint damage by dis- fractures of the hand. ~* ease, traumatic dislocation, or intra-articular Burns and abrasions. The central tendoa fracture may be irreversible. Contracture of the will usually be damaged by a third degree ther- volar plate, capsular ligaments, or sublimis ten- mal or abrasion injury that destroys the skin don may also fix the middle joint in flexion. It is cover over the middle joint. If the lateral bands occasionally feasible to release these are spared, a typical boutonniere deformity will’ Boutonnieredeformity 45 develop. Unfortunately, the joint is also dam- ret~rs t.o this intrinsic imbalanceas an !!intrinsic aged in somecases. intrlnStc p us. ::~. " ...... ~: Rheumatoiddisease. A boutonniere defor- Latedeformities. There is seldom any &ffi- mity may accompanyrheumatoid of the culty in diagnosis of a long-standing classic de- hand when the extensor apparatus is disrupted for:mity aRer the edema and tenderness have by invasive synovitis. Heywood1~ states that the subsided. Other causes of flexion deformity of initial lesion attenuates the central band near its the middle joint such as dorsal bone block, volar insertion. Involvementof the triangular ligament capsule contracture, and derangement of the area then permits the lateral bands to separate flexor mechanismmust be ruled out by thorough and migrate volarward to establish the typical examination. A true boutonniere deformity will deformity. The stretching caused by effusion of have reciprocal extension of the proximal and t~ the middle joint will hasten the distortion of the distal joints, extensor mechanism. TREATMENT Diagnosis Indications for surgery Initial confusion. In traumatic cases involv- The mere existence of the deformity does not ing crush or avulsion, the initial swelling and constitute an indication for treatment. Many pain may be quite severe and voluntary motion patients will experience fairly good function and restricted. This frequently leads to a significant have a minimumof complaints. delay in determining the true diagnosis and ob- Preblems, other than the acute injuries, that taining proper treatment. It is certainly not bring patients for evaluation by the surgeon are, uncommonfor the surgeon to see this problem in approximate order of frequency: appearance, for the first time more that 2 weeksafter injury. clumsiness, repeated injury to a prominent There is usually no roentgenographic evidence knuckle, annoying tightness in the finger, and of fracture, and the finger has generally been pro~ stiffness of the distal joint. tected on a volar splint in slight flexion. The These complaints must be evaluated in the tentative diagnosis is a sprain. Whenfailure of light of the patient’s age and motivation, the active extension of the middle joint finally be-- etiology of the deformity, and the mobility of the comes evident, the true nature of the tendon joints. A proper decision must then be based on problem is suspected. Deformities caused by the probability of offering significant improve- simple lacerations of the central band and de- ment of the patient’s specific complaints. A frank formities due to rheumatoid disease are more discuss~on of treatment, length of disability, and easily recognized. anticipated results will prepare the patient for the Subsequent evaluation. In all cases, an cooperation and effort required to obtain the accurate history of the injury or disease is help- best result. ful. X-ray examination should be routine. In traumatic cases there is usually somepersistent Ac~ate tendon injuries tenderness and edema on the dorsum of the Principles. Prompt treatment of extensor middle joint. Perhaps even a tell-tale bruise or tendon injuries at the middle joint level will repaired laceration over the head of the proximal usually restore good function and prevent pro- phalanx will indicate the level of injury. There is gressive deformity. Fresh lacerations of tendon usually a full range of active flexion of the middle are repaired with the middle joint splinted in and distal joints with a limited range of active full extension. Closed tendon injuries, seen with- extension of the middle joint.- in 2 weeks, are treated simply by splinting. ¯ of the middle oint is 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. Acute boutonnieredeformity. A, Closed avul- Fig. 6-2. Acute boutonniere deformity. A, Laceration in- sion injury. B, Middlejoint pinned in full extension. jury. B, Tendonrepair and middle joint fixed in full (FromElliott, R. A.: Orthop.Clin. N. Amer.1:335-354, extension. (From Elliott, R. A. : Orthop. Clin. N. Amer. Nov. 1970.) 1:335-354, Nov. 1970.) in the office. The distal joint is free to exercise, ercises of the middle joint are encouraged and but only with additional manual support of the distal joint flexion is continued with manual sup- middle .joint. Occasionally a rigid safety-pin port of the middle joint. Active flexion of the splint will be used instead of the wire in a very middle joint is not specifically encouraged during reliable patient. This splint supports the volar the first 2 months. After that time, active and surface of the proximal and middle phalanges as passive exercises at both joints will hasten im- the web strap is tightened over the dorsum of the provement. In patients over 45 years of age, middle joint. The distal phalanx is left unsup- internal splinting is held only 4 weeks and the ported and active flexion of the distal joint is entire program is moved ahead 1 week. encouraged. Results. When treatment has been initiated When there-is a laceration of tendon, the within 2 weeks of the injury and immobilization traumatic wound is extended with an undulating has been effective for the prescribed period, incision to gain exposure and assure an accurate essentially normal function has been recovered. repair. The middle joint is fixed with a Kirschner The internal pin fixation has afforded the most wire before the tendon sutures are placed. A com- reliable immobilization of the middle joint in the plete division of the central tendon is sutured acute injuries, and the wire is tolerated very well. with a continuous 4-0 stainless steel pullout wire (Fig. 6-2). Partial lacerations of the central band Established mobile deformities and lacerations of the lateral bands, are repaired Principles. Surgical reconstruction of the ex-. with buried interrupted 5-0 sutures of nonab- tensor mechanismis indicated in selected cases of sorbable material. A rigid external splint is suffi- established deformity of more than two weeks cient for some incomplete lacerations. duration. If the joints are mobile, prolonged. Postoperative care. Acute injuries are splint- safety-pin splinting 5 or~,9 extensor’1° tenotomy ed for 7 weeks. The internal fixation is main- will offer improved function, but the best results tained for 5 weeks. A safety-pin splint is worn are seen with an anatomic reconstruction of the continuously for an additional week, and then as extensor mechanism.* Long-standing deformi- a night splint during the final week. After the splinting is discontinued, active extension ex- *Seereferences 7, 8, 28, 33, and36. Boutonnieredeformity

B1

C C1 Fig, 6-3. Correctionof establishedmobile boutonniere deformity. A, Normalanatomic rela- tionships. B, Deformitywith retracted central tendonand scar bridge, tear in triangular ligamentarea, and displacementof lateral bandsbelow axis of middlejoint. C, Anatomic repair with fixation of middlejoint in full extension.(From Elliott, R. A. : Orthop.Clin. N. Amer.1:335-354, Nov. 1970.) ties mayrequire weeks or months of preoperative by fir:m traction on the attached scar. A portion splinting to gain full passive motion. The surgery of the latter is serially amputatedas a scar-to-scar is delayed at least until a maximumpassive anastomosis is completed with the cuff of scar motion is obtained, because the final result will preserved on the middle phalanx. Interrupted seldom exceed the preoperative passive range of nonabsorbable sutures are used. The converging motion. lateral bands are approximated with two sutures Technique of repair. The technique of in the triangular ligament area and the central anatomic repair that I use is shownin Figs. 6-3 tendon and scar are trimmed slightly on each and 6-4. General anesthesia and tourniquet con- side to accommodatethese bands in their normal trol are used, and the extensor mechanismis ex- position. posed through an undulating dorsal incision. After the repair is completed, the surgeon The transverse fibers of the retinacular ligament should test the range of passive flexion of the distal joint to determine the need for release of are divided bilaterally and the lateral bands are 36 mobilized from the midportion of the proximal the Oblique fibers of the retinacular ligaments. phalanx to their junction beyond the triangular If a tenodesis effect is evident, the release is done ligament. The scar overlying the middle joint is along the insertion on the sides of the lateral sectioned transversely at least 0.5 cm. proximal band’s and terminal tendon. to the normal insertion of the central band on The postoperative splinting and mobilization the base of the middle phalanx. The scar and programis the same as has been described for the central .band are separated from the ,joint capsule acute tendon injuries. Earlier passive exercise is and reflected to about the midportion of the unwise, for the scar anastomosis maybe stretched. proximal phalanx in an areolar plane deep to In the established deformities, patience is a the vascular mesotenon.27 Good tendon excur- virtue; tlhe recovery of a maximumrange of sion is demonstrable when this dissection is motion may take 9 months. sufficient. Resul.ts. Since 1961 I have used this treat- The middlejoint is fixed in full extension with ment plan in a series of twenty-five patients in- a transarticular Kirschner wire, and the mobi- volving twenty-seven digits. The best results were lized central band is advancedas far as possible 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 dorsum of 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 years in whom a full range of passive motion was obtained before surgery (Figs. 6-5 to 6-7). could be obtained before surgery. Most of the There were fifteen patients, ages 19 to 51 older patients with symptoms were treated with years, with posttraumatic deformities involving a siimp][e tenotomy. fifteen fingers whomet this criterion of full pre- Discussion. The preservation of a cuff of scar operative mobility. Traumatic deformities of the attached to the base of the middle phalanx obvi- thumb and deformities of congenital or rheuma- ates the more complicated bony attachments toid origin were excluded from this group, al- described in the literature. The utilization of a though the anatomic repair has given good portior.~ of the scar to prolong the central tendon results in the small number of such cases treated. obviates the use of a tendon graft. The scar is In the thirteen determinant cases followed at not likely to be stretched provided the immobi- least 8 months, there were two failures related to lization program is followed as outlined. If the reinjury. The recovery of active middle joint scar is stretched by earlier passive flexion of the extension was 180 degrees in nine patients and middle joint, the tendon unit plus scar will again 165 degrees in two patients. Interestingly, both becometoo long to actively extend the joint fully. of the patients with less than full extension gave The good recovery of middle joint extension must a history of associated middle joint dislocation. be attributed in major part to the prolonged At the distal joint, active extension varied from postoperative splinting. 170 to 180 degrees. All patients gained good The recovery of distal joint motion depends flexion at both the middle (90 to 120 degrees) upon an effective advancement of the lateral and distal (40 to 65 degrees) joints. bands. This is accomplished in the anatomic There were no patients over the age of 51 repair by mobilization of the lateral bands and

l~ig. 6-~ ¢~at~d. For legend see opposite page. 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 mobile deformity in a 19-year-old l~ig. 6-6. Established mobile deformity in a 41-year-old male. A~ Preoperative deformity 38 days after untreated man. A~Preoperative deformity 52 days after repair of acute flexion injury. B~Active extension 35 monthsafter laceration (physiotherapy started at 3 weeks). B~Active anatomicrepair. (3, Activeflexion 35 monthspostoperatively. extension40 monthsafter anatomicrepair. (3~ Activeflexion 40 monthspostoperatively. Boutonniere deformity 51 tenotomy must be done proximal to the pre- of the middle joint is not severe, relief of the distal served fibers of the oblique retinacular ligaments joint hyperextension will improve comfort and 6 to avoid a permanent flexion deformity at the function. The more acutely flexed deformities of distal joint. In the absence of adhesions of the the middle joint, however, will require fusion in terminal tendon to the distal half of the middle a functional position. Fusion of the middle joint phalanx or to the distal joint capsule, a combi- is also indicated when grip and pinch are im- nation of lateral band tenotomy and release of paired by joint destruction or irreparable damage the oblique fibers of the retinacular ligament will to stabilizing ligaments. assure creation of a drop-finger deformity. The ’Techniques of repair. The anatomic repair continuity of one or the other must be preserved. tha~: was described for correction of the mobile deformities is used for some deformities with Deformities with impaired passive motion mildly impaired passive extension. The middle Principles. When full passive extension of joint is fixed in maximumextension and the re- the middle joint cannot be obtained by preop- habilitation program is the same as for the fully erative splinting or release of contracted struc- mobile deformities. 9 tures in the volar compartment, a full range of The simple tenotomy introduced by Fowler motion cannot be restored by reconstruction of is usually effective for relief of distal joint hyper- the extensor mechanism. If the flexion deformity extension. The operation is done with local

Fig. 6-7. Established boutonnieredeformity in a 51-year-old manwith full range of passive middlejoint motion.A, Preoperativedeformity 8 monthsafter injury. Initial repair had been held in full extension for only 2 weeks"because of his age." Active and passive flexion were followed by recurrence of the deformity. B, Twoweeks after secondary anatomic repair. Middlejoint pinnedin full extension(4 weeks). C, Active extension4 monthspostoperatively. D, Active flexion at 4 months. (From Elliott, R. A.: Orthop. Clin. N. Amer.1:335-354, Nov. 1970.) 52 Symposium on the hand

anesthesia and it can be an ambulatory pro-. the middle phalanx and then advanced across cedure. the reduced bone ends into the proximal phalanx. Fusion of the middle joint is done through a The end of the wire remains protruding from the dorsal incision. The joint is entered by detach- side of the middle phalanx to facilitate its re.. ment of the central extensor band. The lateral moval in the office. bands are carefully preserved. The cartilagenous llesults. The anatomic repair will usually re.. joint surfaces are removed at the proper angle store an active range of extension that equals the with a small power saw. The bone is sacrificed preoperative range of limited passive motion. As sparingly to avoid carrying the resection beyond with the mobile deformities, one can expect good the bulbous portions. This assures maximum results in the younger patients. However, three apposition and surer union. Severe soft tissue reconstructions have been done for patients over contractures may require a wider resection of the the age of 60 and all three regained active ex- joint, however, to relax the contractures and tension equal to the range of preoperative passive permit fusion in the desired position. A single motion. Kirschner wire is used for immobilization, as Tenotomy has given good relief of symptoms crossed wires tend to distract the bones during and some improvement of function in most pa- the period of normal resorption. The wire is tients. An example of a desireable result is shown passed retrograde through the resected end of in Fig. 6-8.

Fig. 6-11. Establishedboutonniere deformltywi~: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.(From Elliott, R. A.: Orthop. Clin. N. Amer.1:335:354, Nov. 1970.) Boutonniere deformity 53

Fusion of the middle joint is not difficult and Burns and abrasions failure is unusual. Good function depends upon When third degree thermal and abrasion a stable fusion in the best position for the par- injuries destroy the skin cover over the middle ticular digit. The radial two fingers are usually joint, early repair is mandatory to protect the fused in more extension than the ulnar two fin- tendon and joint from progressive damage. gers, but this mayvary with the patient’s desires. 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 ten- don graft repair 26,~°,~ is planned. The applica- tion 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 con- tractures 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 deformi- ties, 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 evalu- ation. 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 approxima- Fig. 6-9. Fixedboutonniere deformity in a 19-year-oldmale. tion of the mobilized bands with two sutures. A, Burn destruction of central tendon at the middle joint Deformities with impaired passive motion are level with tenodesisof distal joint. B, Extensionafter middle joint fusion and conjoined lateral band tenotomy.C, Range treated with tenotomy or arthrodesis. Arthro- of postoperative flexion. (From Elliott, R. A.: Orthop. desis is preferred for sharp flexion contractures Clin. N. Amer.1:335-354, Nov. 1970.) and for patients with advanced joint destruction. Symposium on the hand

A stable fusion is more difficult to obtain in the 16. Kaplan, E. B.: Functional and surgical anatomy of the rheumatoid deformity. Granowitz and Vainio, ll hand, ed. 2, Philadelphia, 1965, J B. Lippincott Co. reporting on a series of 122 cases, indicate some 17. Kilgore, E. S., Jr., and Graham,W. P., III: Operative advantage in the use of two crossed Kirschner treatment of boutonniere deformity, Surgery 64:999, 1968. wires for immobilization. They also suggest in- 18. Landsmeer, J. M. F.: Anatomyof the dorsal aponeu.. serting the proximal phalanx into the base of the rosis of the humanfinger, and its functional signif- middle phalanx when the head of the proximal icance, Anat. Rec. 104:35, 1949. phalanx has been destroyed. 19. Littler, J. W., and Eaton, R. G.: Redistribution of forces in the correction of the boutonniere deformity, REFERENCES J. Bone Joint Surg. 49A:1267, 1967. 20. Mason, M. L.: Rupture of tendons of the hand, Surg. 1. Backhouse, K. M., and Catton, W. T. : An experimental Gynec. Obstet. 50:611, 1930. study of the functions of the lumbrical muscles in the 21. humanhand, J. Anat. 118:133, 1954. Matev, I.: Transposition of the lateral slips of the 2. Bingham, D. L. C., and Jack, E. A.: Buttonholed ex- aponeurosis in treatment of longstanding "boutonniere tensor expansion, Brit. Med. J. 2:701, 1937. deformity" of the fingers, Brit. J. Plast. Surg. 17:281, 1964. 3. Bunnell, S.: Surgery of the hand, ed. I, Philadelphia, 22. Milch, H.: Buttonhole rupture of the extensor tendon 1944, J. B. Lippincott Co. of the finger, Amer. J. Surg. 13:244, 1931. 4. Bunnell, S.: Intrinsic muscles of fingers. Bunnell, S.: 23. Milford, L. W., Jr. : Retaining ligaments of the digits Surgery of the hand, ed. 4 (revised by J. H. Boyes), of the hand, Philadelphia, 1968, W. B. Saunders Co. Philadelphia, 1964, J. B. Lipplncott Co. 24. 5. Bunnell, S.: Rupture of tendons. In Bunnell, S.: Montant, R., and Baumann, A.: Anatomical research in the system of the extensor tendons of the fingers, Surgery of the hand, ed. 4 (revised by J. H. Boyes), Ann. d’Anat. Path. 14:311, 1937. Philadelphia, 1964, J. B. Lippincott Co. 25. Montant, R., and Baumann, A.: Rupture luxation of 6. Dolphin, J. A.: Extensor tenotomy for boutonniere de- the extensor apparatus of the fingers of the first inter- formity of the finger, Proceedings of the Americanso- phalangeal articulation, Rev. d’Orthop. 25:5, 1938. ciety for surgery of the hand, J. Bone Joint Surg. 45A: 26. Nichols, H. M.: Repair of extensor tendon insertion in 878, 1963. fingers, J. Bone Joint Surg. 33A:836, 1951. 7. Elliott, R. A.: Extensor tendon injuries at the inter- 27. Smith, J. W.: Tendon injuries. In Grabb, W. C., and phalangeal joint levels. Presented to the AmericanSo- ciety for Surgery of the Hand Meeting, Chicago, Jan. Smith, J. W., editors: Plastic surgery, Boston, 1968, Little, Brownand Co. 1965. :_78. 8. Elliott, R. A.: Injuries to the extensor mechanismof Smith, R. J. : Boutonniere deformity of the fingers, Bull. Hosp. Joint Dis. 27:27, 1966. the hand, Ortho. Clin. N. Amer. 1:335, Nov. 1970. ’29. Stack, H. G. : Muscle function in the fingers, J. Bone 9. Fowler, S. B. : Extensor apparatus of the digits, J. Bone Joint Surg. 44B:899, 1962. Joint Surg. 31B:477, 1949. 30. Tubiana, R.: Surgical repair of the extensor apparatus I0. Goldner, J. L.: Deformities of the hand incidental to of the fingers, Surg. Clin. N. Amer. 48:1021, 1968. pathological changes of the extensor and intrinsic 31. Tubiana, R., and Valentin, P.: The anatomy of the muscle mechanisms, J. Bone Joint Surg. 35A: 115, 1953. 1 I. Granowitz, S., and Vainio, K.: Proximal interpha- extensor apparatus of the fingers, Surg. Clin. N. Amer. langeal joint arthrodesis in , Acta 44:897, 1964. 32. Tubiana, R., and Valentln, P.: The physiology of the Orthop. Scand. 37:301, 1966. 12. Hauck, G.: Die Ruptur der Dorsalaponeurose am extension of the fingers, Surg. Clin. N. Amer. 44:907, ersten Interphalangealgelenk, zugleich ein Beitrag zur 1964. 33. Verdan, C. E.: Repair of tendons. In Flynn, J. E., Anatomic und Physiologic der Dorsalaponeurose, Arch. editor: Hand surgery, Baltimore, 1966, The Williams klin. chir. 123:197, 1923. 13. Heywood, A. W. B.: Correction of the rheumatoid & Wilkins Co. 34. Weeks, P. M.: The chronic boutonniere deformity: A boutonniere deformity, J. Bone Joint Surg. 51A:1309, 1969. method of repair, Plast. Reconstr. Surg. 40:248, 1967. 35. Weitbrecht, J.: Syndesmologia sive historia ligamen- 14. Kaplan, E. B.: Extensor deformities of proximal inter- torum corporis humani, quam secundum observationes phalangeal joints of fingers, J. BoneJoint Surg. 18:781, 1936. anatomicas concinnavit, et figuric and objecta recentia adumbratic illustravit. Petropoli, 15. Kaplan, E. B.: Pathology and operative correction of ex typographia finger deformities due to injuries and contractures of Academiae Scientiarum Anno 1742. 3(;. Zancolli, E.: Structural and dynamic bases of hand the extensor digitorum tendon, Surgery 6:35, 1939. surgery, Philadelphia, 1968, J. B. Lippincott Co. apparatus. The release of the deformity is Discussion accomplished by dividing the interossei and the rel:inacular ligaments. We don’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 Dr. Chase: I also would like to select only very of the original ailment. If we do these first cooperative patients under the age of 45 for and then obtain flexion of the joint, and then all surgery, if possible. advance this and relocate the extensor ten- Dr. Zancolli: Speaking of results of treatment of don, we will have a good result in this the boutonniere deformity, I think it is very retinacular stiffness. important to know the exact pathology of the In the third period, things are more com- deformity, because the results of treatment plicated because we see that not only is the are contingent upon this pathology. I believe retinacular ligament tight, but also there is that the operation that Dr. Elliott presented a retraction of the volar plate. We have re- works. We have been doing the same opera- traction of the retinacular ligament, and this tion for at least the last 15 years. This opera- is not only ligamentous stiffness, it is articular tion gives excellent results only under certain stiffness. In this case it is very difficult to circumstances, however. obtain a good result, even with the retinacu- In the evolution of the deformity, there lar release. are three different periods. Initially, even If you want to try treatment at this stage, with the rupture of the central tendon and the operation is very complicated, but it is the dislocation of the lateral tendon, the possible to try it. The first step is the release longitudinal or oblique portion of the reti- of the retinacular ligament, of course on both nacular ligament is relaxed, because the sides. This is very important. Then a cap- distance between its origin and insertion is sulecmmy is done, supplemented by a release shortened. To demonstrate the oblique reti- of the proximal part of the volar plate. nacular ligament laxity in this period of Dr. Chase: These additional points I think are deformity, it is still possible both to extend terribly important and I am sure Dr. Elliott the middle joint and to flex the distal joint, will want to address himself to them. because the retinacular ligament is relaxed. Dr. Little:r: I have great respect for Dr. Zancol- Later, in the second period of the deformity, li’s analysis of this problem, because I have the retinacular ligament retracts because now run inl:o problems in a rather similar fashion. this has been filled with scar tissue. It seems very important, as he points out, to Now the retinacular test shows that the direct the displaced forces dorsally so the PIP joint extension does not allow the distal extensor and the intrinsic mechanisms, which joint to flex. Not only is it impossible to flex, are acting in the deformity as flexors of the but it also has increased tension. If we em- joint, are converted to be just extensors. It ployed the operation Dr. Elliott showed in seems to me that, although the oblique reti- this case, failure is going to result. It is im- nacular ligament does tighten with time, if possible to obtain a good result in this con- the extensor forces are directed dorsally to dition with that operation unless, when we correct the displacement, and the oblique finish the operation, we can have partial retinacular ligament is relieved bilaterally so flexion of the joint. I feel we must release the that the tip doesn’t drop, quite often exten- deformity, and then reconstruct the extensor sion of the PIP joint can be regained--pro- 55 56 Symposium on the hand

vided, of course, that the lower fibers of the Dr. Chase: I think that is a very important point. collateral ligaments and the volar plate are One thing the scar tissue does is to contract, not irretrievably contracted. if given the opportunity. Since this is one of The oblique retinacular ligament is the the circumstances in which it can do so, I only thing left--unless you leave the lumbri- think the boutonniere has to be pretty much cal--to extend the terminal phalanx. If you a fixed deformity before one would operate can, in directing the displaced extensor forces on it. to the dorsum of the finger, gain extensio:n Dr. Tupper: There is one additional injury that within the passive range, as the PIP joint masquerades as the classical boutonniere de- extended, it will tighten the oblique retinac- formity. This is a closed injury on each of th.e ular ligament. The terminal phalanx will be three cases I have explored. I wonder how dynamically tenodesed and extended auto- many have been missed. The usual pathology matically. Then, with flexion of the PIP joint, shows that the central slip is completely intact the oblique retinacular ligament is released[, across the dorsum, the lateral band has split and finger flexion is possible. across the condyle of the proximal phalanx, This is a tricky mechanism, and I don’t and the collateral ligament has ruptured believe that there is a simple answer to solve allowing the lateral band to become incar- the problem, but you do try to correct, inso- cerated in the intercondylar notch. If a little far as is possible, the pathologic condition, xylocaine is put into this joint and stress films restoring it so that at least all the extensor are taken, one can pick up this particular forces which have been displaced are now variation of the injury on x-ray, but not on acting on the dorsum of the PIP joint. routine films. Dr. Boyes: In this illustration that Dr. Zancolli To treat these three patients I have re- made showing the hyperextension of the dis- reduced the lateral band, brought it up and tal joint, when you bring the middle joint up sutured it to the main tendon with a running in restoring the position, we call this the suture. I have not dealt with the collateral "intrinsic intrinsic plus" finger. In other ligament except to put it in place. Although words, it is the same idea as testing for the it has been a stable affair after the lateral intrinsic tightness of the interossei. You ex- band has come up, all three of them have tend the metacarpophalangeal joint and the had bad results. middle joint stays in extension. Dr. Elliott: I find agreement with most of Dr. Most surgery for the boutonniere de.- Zancolli’s discussion and this basic agreement formity is a complete waste of your time and will be more evident with review of my full effort. The expense to the patient and the use manuscript. Release of the contracted oblique of the hospital beds, which could be occupied retinacular ligaments is indicated only when by other patients on whomI would rather do these ligaments exercise a tenodesis effect on some surgery, are also bothersome. I think the lateral bands, preventing their advance- most can be treated by splinting. If the splint.. ment and thus limiting flexion of the distal ing is applied properly, you can do it as late joint. But this can be tested for after comple- as 30 days after the injury, the idea being to tion of the anatomic repair, and the release splint the middle joint only, in full extension, is simply added when needed. and not to splint the distal joint. The distal Dr. Littler’s operation for redistribution joint must remain free. You leave the splint: of the extensor forces requires section of both on for a minimum of 5 weeks--long enough lateral bands. If section of the oblique reti- so that with the middle joint in extension on nacular ligaments is added to this operation, the splint, the patient can voluntarily flex a drop finger deformity will occur at the the distal joint to the same degree as on his distal joint. opposite normal finger. It must be emphasized that, in any given The retinacular ligament,which has been method of repair, either the lateral bands or shortened, has relengthened and stretched the oblique retinacular ligaments must be out. Five weeks is enough time for the scar left intact to avoid a drop finger deformity of tissue to heal. The results are extremely good, the distal joint. In the anatomic repair it is in spite of the fact 1hat we don’t select only usual to preserve both. the 4 l-year-olds and the cooperative patients. 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, Palo Alto, 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