15 Relative Motion Treatment of Chronic Boutonniere Deformity
15.1 Patient History Leading to the Specific Problem
A 48-year-old woman had a 6-month fixed flexion contracture of her middle digit that was swollen, painful, and had lost flexion in both interphalangeal (IP) joints as well as extension of her proximal interphalangeal (PIP) joint following a jam-type injury in a fall. She explained it had been diagnosed initially as an “occult fracture” and then as a “volar plate injury” that was “unresponsive to hand therapy.” She complained about discomfort and loss of motion.
15.2 Anatomic Description of the Patient’s Current Status
The patient was distressed due to chronic pain and swelling of her PIP joint and had lost flexion in her distal interphalangeal (DIP) joint from hyperextension remodeling of her dorsal capsule, and had also lost some flexion in her PIP joint as well as extension, with a fixed PIP flexion contracture of −45 degrees of active extension and −35 degrees of passive extension (“fixed contracture”) due to volar joint capsule remodeling. A Boyes’ test was distinctly positive. Her Elson’s and modified Elson’s tests were equivocal because of her decreased motion and fixed flexion contracture. Her X-ray was normal (▶Fig. 15.1).
15.3 Recommended Solution to the Problem
There are numerous proposed operations for chronic boutonniere deformity, all of which have uncertain, usually poor, results. This is especially true if the contracture has been present for 3 months or more, initially presents with greater than −30 degrees of active extension, and if the patient is older than 45 years; this patient had all of these characteristics with greater than 50% probability of a poor surgical result. All patients with fixed contractures from chronic boutonniere deformity need serial casting to recover full passive extension when possible and we believe nonsurgical management techniques should be attempted.
In this patient, we utilized serial casting with progressive forced extension changed twice a week, with minimal padding (▶Fig. 15.2a, b). When −5 degrees was obtained, improvement plateaued, and relative motion flexion splinting was initiated, with therapy attention directed toward recovering full PIP flexion and the achieved extension maintained in the splint full time while using her hand for normal functional activities. This is accomplished by placing the injured digit in 15- to 20-degree greater flexion relative to the adjacent metacarpophalangeal joints and encouraging active motion and digit functional use (▶Fig. 15.2c, d). When she became almost able to touch her palm, she was encouraged to resume all her normal previous activities in the splint (▶Fig. 15.2e, f).
15.5 Postoperative Photographs and Critical Evaluation of Results
After 3 months, she maintained her −5 degree PIP extension, and recovered 90 degrees of PIP flexion, and the splint was discontinued, though she still lacked full DIP flexion (▶Fig. 15.3a, b). At 3 years, her extension is slightly improved, and she now has full composite flexion. She is pleased with her final result (▶Fig. 15.3c, d).