Journal international de médecine physique et de réadaptation
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Abstrait

A Novel Management Technique for Acute and Chronic Boutonniere Deformity that Permits Immediate Active Motion and Functional Hand use

Wyndell H. Merritt*

Introduction: Conventional management of acute boutonniere deformity usually involves immobilization and typically results in two to four months out of work. Chronic fixed boutonniere often defies any acceptable correction with surgical or nonsurgical efforts. This is likely due to the delicately balanced interwoven but moveable shroud of supportive dense connective tissue at the extrinsic-intrinsic interface, which can adhere to the underlying bony phalanges during immobilization. We propose a safe method for early motion and hand use that can reduce adherence.

Methods: An understanding of the normal extrinsic-intrinsic anatomic relationships of adjacent digits takes advantage of variable forces at the inter phalangeal level when the Meta Carp Phalangeal (MCP) joints are in differing positions relative to one another. We call this the “relative motion concept,” which permits safe active motion with orthosis that protect the involved digit. Twenty-three patients with acute and chronic boutonniere deformity had their injured digit placed in a 15-20 degree greater MCP flexion orthosis compared to the adjacent digits, and were encouraged to otherwise maintain normal motion and use. The orthosis was maintained for six weeks in acutely injured patients. In fixed chronic cases, serial casting was used to achieve as much extension as possible (averaging minus 5 degrees), then a Relative Motion Flexion (RMF) orthosis was used for three months.

Results: The acute cases achieved as good or better range of motion as conventional management methods, maintaining full flexion and extension, and little or no therapy needed after six weeks of splinting. Patients with chronic boutonniere deformity maintained the extension achieved by serial casting (averaging minus 5 degrees extension) and all were able to flex to their palm. Range of motion improvement averaged 36 degrees.

Conclusion: For acute boutonniere deformity, this management technique significantly reduced morbidity, allowing functional use while healing and less therapy following treatment. For chronic boutonniere deformity, serial casting and prolonged use of RMF orthosis proved an attractive alternative to surgery.