THE MIDDLE SLIP OR BOUTONNIERE DEFORMITY IN BURNED HANDS

Anatomic Repair of the Central Slip with Anchor Suture Augmentation for Treatment of Established Boutonniere Deformity

Backgroud

The rupture of the central slip of an extensor tendon of a finger causes a boutonniere (or buttonhole) deformity, characterized by pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Currently, there are no standard treatment guidelines for this deformity. This study aimed to report clinical results of surgery to correct chronic boutonniere deformity.

Methods

This retrospective case series was conducted between January 2010 and December 2018 and only 13 patients with trauma-induced chronic deformity were included. After excision of elongated scar tissue, a direct anatomic end-to-end repair using a loop suture technique with supplemental suture anchor augmentation was conducted. Total active motion was assessed before and after surgery and self-satisfaction scores were collected from phone surveys.

Results

All patients presented with Burton stage I deformities defined as supple and passively correctable joints. The initial mean extension lag of the PIP joint (43.5°) was improved by an average of 21.9° at the final follow-up (p < 0.001). The mean hyperextension of the DIP joint averaged 19.2° and improved by 0.8° flexion contracture (p < 0.001). The average total active motion was 220.4° (range, 160°–260°). Based on the Souter's criteria, 69.2% (9/13) of the patients had good results. Only 1 patient reported fair outcome and 23.1% (3/13) reported poor outcome. The average Strickland formula score was 70 (range, 28.6–97.1). In total, 10 patients (77%) had excellent or good results. Of 10 patients contacted by phone, self-reported satisfaction score was very satisfied in 2, satisfied in 3, average in 3, poor in 1, and very poor in 1. Three patients reported a relapse of the deformity during range of motion exercises, 1 of whom underwent revision surgery. One patient complained of PIP joint flexion limitation, and 2 complained of DIP joint flexion limitation at final follow-up.

Conclusions

In chronic boutonniere deformity, central slip reconstruction with anchor suture augmentation can be an easily applicable surgical option, which offers fair to excellent outcome in 77% of the cases. The risk of residual extension lag and recurrence of deformity should be discussed prior to surgery.

Postburn Contractures of the Hand

Postburn contractures are a common occurrence after severe burn injuries. It is important to understand the pathologic condition and anatomy of specific postburn deformities in order to provide comprehensive surgical care. Postburn contractures can result in a flexion contracture, boutonniere deformity, burn syndactyly, metacarpophalangeal extension contracture, wrist contracture, or claw hand. A patient evaluation is performed before proceeding to the operating room. Surgery sequences require proper incision design, release of the skin, and deeper contracted structures and coverage with an appropriate flap or graft. Postoperative splinting, scar care, and therapy are equally important for a successful outcome.

Rehabilitation of the burned hand

Successful outcomes following hand burn injury require an understanding of the rehabilitation needs of the patient. Rehabilitation of hand burns begins on admission, and each patient requires a specific plan for range of motion and/or immobilization, functional activities, and modalities. The rehabilitation care plan typically evolves during the acute care period and during the months following injury.

A study of bone and joint changes secondary to burns

A clinical and radiological study of 80 postburn patients to determine the extent of bone and joint changes is presented. The group comprised 38 males and 42 females, with ages ranging from 2 to 60 years. The time since burning ranged from 6 to 12 months in 40, from 1 to 5 years in 24 and over 5 years in 16 patients. Clinically bone and adjoining tissue involvement were seen in 32 patients (40 per cent), while radiological changes were seen in 49 (61.25 per cent). Radiological changes noted included osteoporosis 56.25 per cent, stunted growth (phalanges and limbs) 27.5 per cent, osteomyelitis 2.5 per cent, partial resorption of terminal phalanges and ankylosis 1.25 per cent each. Periarticular, pericapsular and tendon calcification were each seen in 1.25 per cent of the patients. Bone and joint changes were encountered only in major burns, and these could be minimized by proper early surgical care and long-term rehabilitation.