M20.02 Boutonnière deformity
M20.021 Boutonnière deformity of right finger(s)
M20.022 Boutonnière deformity of left finger(s)
M20.029 Boutonnière deformity of unspecified finger(s)
PREFERRED PRACTICE PATTERN
4E: Impaired joint mobility, motor function, muscle performance, and ROM associated with localized inflammation1
The patient is a 42-year-old man who owns a landscaping business. He reports he was injured approximately 2 months ago while trying to clear grass from around a lawnmower blade, resulting in the loss of skin on the top of his middle finger. On examination in the emergency room, he was found to have full thickness skin loss of about 2.5 cm in diameter from the dorsum of the proximal interphalangeal (PIP) joint of the R middle finger; damage to the central tendon was also apparent. The surgeon debrided the wound and covered the joint using a pedicle flap from the radial side of the adjacent ring finger, and a partial thickness graft to the donor site. The doctor positioned the finger near full extension; subsequent release of the flap from the adjacent finger was done and healing occurred without complication.
Though cautioned against PIP flexion, or use of the hand that involved the finger, the patient reported he had resumed his work out of necessity, though on a limited basis. He presents with a stiff, enlarged PIP joint held in flexion at 40 degrees, and DIP joint at 10 degree hyperextension. He is unable to actively extend his PIP, and passive motion is limited to 10 degree extension from the initial measurement after treatment. Active and passive flexion of the DIP is limited to 5 degrees.
The tendons attaching to the middle phalanx. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
Generally from a forceful blow to a flexed finger
Severed central slip tendon
Signs and symptoms may develop in acute to subacute phase of injury
Flexion of the PIP joint and extension of the distal interphalangeal (DIP) joint2
Injury to the central slip tendon and often damage to the volar plate
Volar displacement of the lateral bands
Shortening of the oblique retinacular ligament
Boutonnière splint. The finger is splinted with the proximal interphalangeal joint held in extension. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
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