Vol. 8, No .

2
March 1983 Degeneratil'e j oint disease of trape;illm

37 . Muller G : Arthrodesis of the trapezio-metacarpal joint 39. Dickson R: Arthritis of the carpometacarpal joint of the
for osteoarthritis. J Bone Joint Surg [Br] 31 :541-3, 1949 thumb: Treatment by silicone sponge interposition ar-
38. Patterson R: Carpometacarpal arthroplasty of the thumb. throplasty. Hand 8: 197-208, 1976
J Bone Joint Surg 15:240-1, 1933

A staged technique for the repair of the

traumatic boutonniere deformity
A step-by-step approach to the systematic management of chronic boutonniere deformity due to
trauma is presented. If surgical intervention is necessary, the problem should be approached one
step at a time. The following stages are described: stage I, tendolysis of the extensor tendon and
freeing of the transverse retinacular ligament; stage II, sectioning of the transverse retinacular
ligament; stage III, tendon lengthening of the lateral bands over the middle phalanx; and stage
IV, repair of the central extensor tendon. After managing 23 patients according to this plan, we
have concluded that it is frequently unnecessary to automatically go through all four stages in
treating chronic traumatic boutonniere deformity. We found that 17 patients were successfully
managed by some combination of stages I, II, and III, and six patients received adequate treat-
ment with stages I, II, and IV. (J HAND SURG 8:167-71, 1983.)

Raymond M. Curtis, M.D., Robert L. Reid, M.D., and John M. Provost, M.D.,
Baltimore. Md .• Owensboro. Ky .. and Washington. D.C.

Although a damaged central extensor slip
and resultant boutonniere defonnity has been known to
surgeons for many years, there is no unanimity regard-
ing treatment and no systematic approach to the chronic
problem, caused by trauma, has been presented in the
literature. The plan described here was developed by
one of the authors (R . M. C.) and allows the surgeon
alternatives of therapy for any eventuality .
Material and methods
Twenty-three patients , ranging in age from 17 to 57
years, were treated for chronic traumatic boutonniere
defonnity. All of the injuries were originally open and
had generally been caused by laceration with a sharp
instrument. In no case was the defonnity diagnosed at
the first medical visit and none of the patients had had
primary repair of the tendon. Several of the patients had
been splinted in a position of flexion for a period of 4 to
6 weeks; the boutonniere defonnity became apparent
Received for publication Oct. 22, 1982.
Reprint requests: Dr. Raymond M. Curtis, 2947 SI. Paul St .. Balti-
more, MD 21218.
when the splint was removed . It was at this point that
further medical attention was sought, either because of
decreased strength of grasp with the involved finger or
of the bent position of the digit. There were 17 patients
who received operatively some combination of stage I,
II, and Stage III treatment. Preoperatively, they lacked
an average of 41 0 in their ability to extend the affected
digit in a straight line at the proximal interphalangeal
(PIP) joint. There were six other patients who required
stage IV, instead of stage III treatment in addition to
stages I and II. Preoperatively, these fingers lacked 55 0
of extension at the PIP joint.
Plan of management
The following plan of management, successfully
executed in the aforementioned cases, is recommended
for all patients with chronic traumatic boutonniere de-
fonnity.
When the defonnity has reached the chronic stage
and before treatment is begun , splinting will be re-
quired to stretch out the contracted palmar capsule of
the stiff PIP joint. t If capsular stiffness is not corrected
by splinting, it will have to be treated surgically before
THE JOURNAL OF HAND SURGERY 167
 The Journal of
168 Curtis et al. HAND SURGERY

Fig. 1. A, Preoperative photograph showing patient attempting active extension; the finger lacks 50°
extension at PIP joint. Surgeon begins stage I by making a lazy "S" dorsal incision centered on the
PIP. B, (stage I), Freeing of adherent transverse retinacular ligament with elevator illustrated on one
side but carried out on both sides of joint. C, (stage I), Tendolysis of scarred and adherent extensor
tendon over the PIP. D, Tourniquet is released and patient is asked to extend finger. Photograph
demonstrates full extension following stage I procedure.

a second operation to repair the boutonniere deformity

can be performed. In the event that it is impossible to
correct the capsular stiffness, a Swanson prosthetic re-
placement is indicated. None of the patients ' in our
series required this procedure.
Full passive extension is a prerequisite for surgery in
STAGE I these cases. Once that has been assured, the surgeon
may begin the first stage of the boutonniere correction.
The procedure should be performed in the operating
room and local anesthesia consisting of a palmar digital
Transverse nerve block and a dorsal sensory nerve block at the
retinacular I ig.
sectioned
metacarpophalangeal (MP) joint should be adminis-
tered at the outset. Innovar or other analgesic means
may be used to supplement the nerve block. However,
the patient should be prepared to accept general or axil-
lary block anesthesia if it becomes necessary to con-
tinue to stage IV.
In stage I, the surgeon begins by making a lazy "S"
Fig. 2. Stage I, tendolysis of extensor tendon; freeing of dorsal incision, centered on the PIP joint (Fig. 1, A).
transverse retinacular ligament, and stage II, tendolysis The transverse retinacular ligament is visualized on
of extensor tendon; sectioning of transverse retinacular both sides of the extensor tendon and freed distally and
ligament. proximally by a blunt probe (Fig. I, B). A tendolysis of
Vol. 8, No . 2
March 1983
Fig. 3. A, Dorsal splint with outrigger and leather loop with rubber band allows early flexion but
maintains extension . B, Postoperative result demonstrates active extension after 6 months. C,
Postoperative result demonstrates flexion after 6 months.
the extensor tendon is performed (Fig . 1, C) and a
small scalpel is placed beneath the extensor tendon ,
freeing it from the dorsal capsule . The central tendon,
bridged with scar tissue, adheres to the dorsal capsule.
The tourniquet is released and the patient is asked to
extend the finger . If full extension is present (Fig. I,
D), no further exploration is needed; the deformity has
been corrected at stage I.
However, if full extension is not present, the surgeon
proceeds with stage II. The previously freed transverse
retinacular ligament is now sectioned throughout its
length on both sides of the finger just palmar to the
lateral band (Fig. 2) . This allows increased excursion
of the extensor tendon and the lateral band as they
insert into the central tendon. Again, the tourniquet is
released and the patient is asked to extend the digit.
Approximately 30% to 40% of the patients are now
able to fully extend at the PIP joint and thus require no
further surgery: the deformity has been corrected at
stage II. The wound is closed and a bulky hand dressing
is applied , into which is incorporated a combination
dorsal and palmar splint, maintaining the MP joint in
approximately 70° of flexion and the PIP and distal
interphalangeal (DIP) joints in 0° of flexion. On about
the sixth or seventh postoperative day, the patient's PIP
joint is held in extension by a dorsal plaster splint with
Repair of' boutonniere deformity 169
a small coat hanger outrigger and a loop in a rubber
band (Fig. 3, A). A MP joint block is accomplished in
this way . The patient is told to actively flex and extend.
In about 3 to 4 weeks the splint is removed, but the
patient is encouraged to exercise the digit by active
extension and flexion. A satisfactory result is usually
achieved within 6 months (Fig. 3, B and C).
There are some patients who , after the tourniquet is
released at stage II, fall 20° short of a straight line in
their ability to fully extend the involved finger at the
PIP joint. This indicates that in the healing process a
gap has developed in the central tendon . These patients
require further surgery (stage III) . A modified Fowler
tenotomy2 ' 3 is performed in such a way as to prevent
the development of a mallet finger.4 The lateral bands
over the middle phalanx are sectioned and step-cut and
the lengthened tendon is sutured. The injured and
thereby mildly lengthened central slip is now balanced
mechanically by the surgically lengthened lateral band .
The properly balanced extensor mechanism will now
extend the middle phalanx as well as the distal phalanx
(Fig. 4).
If the tourniquet is released after stages I and II and
the patient is unable to fully extend the digit by greater
than 20°, the gap in the central tendon where healing
has occurred is too large to be corrected by stage III .

170 Curtis et al.
Tendon lengthening
STAGE III
Fowler tenotomy
Fig. 4. Stage III, lengthening of lateral bands over middle
phalanx or tenotomy of extensor tendon.
STAGE IV
Zancolli repair
A The 23 patients in our study were followed for vary-
Central
tendon
Fig. 5. Stage IV. repair of central extensor tendon.
The surgeon should then go directly to stage IV, as we
did in our treatment of approximately 38% of the pa-
tients in this study. In approaching stage IV, several
operative techniques are possible. Matev ;' Littler,S
Rothwell/ and Van der Meulen 8 have all outlined dif-
ferent methods. However, the technique we prefer is
that described by Zancolli, 9 Elliott, to and others, t 1. t2 , 13
where the central tendon is separated away from the
lateral bands (Fig. 5). In this procedure the surgeon
either advances the central tendon about 4 to 6 mm into a
drill hole in the dorsal base of the middle phalanx or
sutures the extensor tendon to its remnant left at the base
of the middle phalanx. The lateral bands, which now
The Journal of
HAND SURGERY
BOUTONNIERE DEFORMITY
Pre-op Post-op
STAGE 1-11-111
/.
STAGE HV
Fig. 6. Diagram shows average lack of extension, preopera-
tively and postoperatively. for patients managed by combina-
tion of stage I, II. and III and for those managed by stage I
through IV.
seem superfluous, are loosely sutured to the central
tendon .
Results
ing lengths of time for up to I year postoperatively. The
17 patients who had lacked an average of 41 ° of exten-
sion at the PIP joint preoperatively lacked an average of
10° postoperatively, while the six patients who had
lacked 55° preoperatively and had required stage I V
improved to the point where they lacked only an aver-
age of [70 postoperatively (Fig. 6) . The final result for
the determination of flexion ability was measured in
relation to the distal palmar crease. All but three pa-
tients demonstrated an increased ability to touch or ap-
proximate the distal palmar crease and among all 23
patients there was a lack of touching the distal palmar
crease by an average of only I cm.
Conclusion
The staged method of surgical intervention in the
treatment of a chronic traumatic boutonniere deformity
frequently allows a less complex procedure to be per-
formed in the involved digit. With this plan of man-
agement, the surgeon is able to divide the boutonniere
deformity into various categories and then use the op-
erative procedure indicated for each particular problem,
often avoiding unnecessary surgery,
REFERENCES
L Boyes JH : In Bunnell's surgery of the hand, ed 5.
Philadelphia. 1970. JB Lippincott Co, pp 439-42
2, Fowler SB. (1962) quoted by Littler JW: In Converse
Vol. 8, No.2
March 1983 Repair of boutonniere deformity

1M, editor: The hand and upper extremity in reconstruc-
tive plastic surgery, ed 4. Philadelphia, 1964, WB Saun-
ders, p 1630
3. Dolphin JA: Extensor tenotomy for chronic boutonniere
deformity of the finger. 1 Bone 10int Surg [Am] 47:
161-4, 1965
4. Goldner lL: Deformities of the hand incidental to
pathological changes of the extensor and intrinsic muscle
mechanisms. J Bone Joint Surg [Am] 35:115-31,1953
5. Matev I: Transposition of the lateral slips of the
aponeurosis in treatment of long-standing "boutonniere
deformity" of the finger. Br 1 Plast Surg 17:281-6, 1964
6. Littler lW, Eaton RG: Redistribution of forces in the
correction of the boutonniere deformity. 1 Bone 10int
Surg [Am] 49:1267-74, 1967
7. Rothwell AG: Repair of the established post traumatic
boutonniere deformity. Hand 10:241-5, 1978
8. Van der Meulen lC: Treatment of prolopse and collapse
of the proximal interphalangeal joint. Hand 4: 154-62,
1972
9. Zancolli E: Structural and dynamic basis of hand sur-
gery, ed 2. Philadelphia, 1979, 18 Lippincott Co, pp
79-92
10. Elliott RA lr: Boutonniere deformity, In Cramer LM,
Chase RA, editors: Symposium on the hand. St Louis,
1971, The CV Mosby Co, vol III, pp 42-54
II. Kaplin EB: Anatomy injuries and treatment of the exten-
sor apparatus of the hand and the digits. Clin Orthop
13:24-41, 1959
12. Souter W A: The problem of boutonniere deformity. Clin
Orthop 104:116-33, 1974
13. Tubiana R: Surgical repair of the extensor apparatus of
the fingers. Surg Clin North Am 48:1015-31, 1968

Free nail bed graft for treatment of nail bed

injuries of the hand
Free full-thickness grafts of nail bed of the lesser toes or an amputated fingertip were successfully
performed on 11 fingers of 10 patients since 1979. In nine patients in whom the nail beds had been
severely crushed or lost, but the nail matrix was intact, the end results of this technique were
excellent. In one patient in whom both the nail bed and matrix had been lost, free grafting of the
toenail bed and matrix was performed, with a good result. The procedure can be used when
restoring the length of the tip in fingertip amputation if used in combination with local skin flaps
such as V-Y advancement or local rotation flaps. (J HAND SURG 8:171-8,1983.)

Hidehiko Saito, M.D., Yorio Suzuki, M.D., Keiji Fujino, M.D., and
Tatsuya Tajima, M.D., Niigata, Japan

T he injured nail poses a significant prob-
lem in treating the fingertip injury. An understanding of
the functional anatomy and histology of the nail and its
surrounding structure is essential for its proper treat-
ment (Fig. 1, A). Cells of the nail matrix become flat-
tened and eosinophilic as they progress superficially,
transforming into the nail plate. The superficial layer of
From the Department of Orthopaedic Surgery, Niigata University
School of Medicine, Niigata, Japan.
Received for publication Nov. 4, 1981.
Reprint requests: Dr. H. Saito, Department of Orthopedic Sur-
gery, Niigata University School of Medicine, Asahimachidori 1,
Niigata-ken 951, Japan.
the nail bed is basophilic and abundant in spinous cells
and adheres to the nail plate, but is clearly demarcated
from it (Fig. 1, B).
When the nail bed has been severely crushed or
avulsed but the matrix is intact, we have in the past
used split skin grafts, intermediate dermal or reverse
dermal grafts (advocated by Kleinert!), or allowed sec-
ondary healing to take place. 2 None of these techniques
have resulted in normal-looking nails. A deformed nail
creates both cosmetic and functional problems. Patients
may complain of pain around the deformed nail and
occasionally a paronychia develops.
We have achieved normal-looking nails by free graft-
ing full-thickness nail bed from the lesser toes or an

THE JOURNAL OF HAND SURGERY 171