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TC(1076).(05).Orthopedics Case No 152:- Boutonniere Deformity

Boutonniere Deformity — বাংলায় Core Clinical Answer

Important clinical point: Boutonniere deformity-তে মূল সমস্যা central slip extensor tendon injury। তাই definitive treatment হলো PIP joint extension splint/hand therapy ± surgery। ওষুধ deformity ঠিক করে না—শুধু pain, swelling, inflammation বা underlying rheumatoid arthritis control করে।

1. Definition

Boutonniere deformity হলো আঙুলের এমন deformity যেখানে:

  • PIP joint flexion হয় — middle joint বাঁকা হয়ে যায়
  • DIP joint hyperextension হয় — fingertip joint অতিরিক্ত সোজা/পেছনের দিকে টান পড়ে
  • মূল কারণ সাধারণত central slip of extensor tendon rupture/injury

AAOS অনুযায়ী splint PIP joint সোজা রেখে tendon healing-এ সাহায্য করে এবং DIP joint bend করা চালু রাখতে বলা হয়।

2. Etiology / Pathophysiology — Cause গুলো

Common causes

  • Jammed finger / stubbing injury
    • বল, দরজা, পড়ে যাওয়া, খেলাধুলার injury
    • PIP joint flexed অবস্থায় আঘাত পেলে central slip ছিঁড়ে যেতে পারে
  • Cut injury / laceration
    • ধারালো বস্তুতে আঙুল কেটে central slip tendon কেটে গেলে
  • PIP joint dislocation
    • বিশেষ করে volar dislocation বা forceful flexion injury
  • Rheumatoid arthritis
    • Chronic synovitis → extensor mechanism দুর্বল → deformity
  • Burn/scar contracture
    • dorsal finger skin/tendon tightness হলে deformity হতে পারে

Pathophysiology — সহজ ভাষায়

Central slip ছিঁড়ে গেলে PIP joint সোজা করার শক্তি কমে যায়। পরে lateral bands নিচের দিকে/ভোলার দিকে migrate করে, ফলে PIP flexion বাড়ে। একই সঙ্গে terminal extensor mechanism tension-এর কারণে DIP hyperextension দেখা যায়। Orthobullets classic deformity হিসেবে PIP flexion ও DIP extension উল্লেখ করেছে।

3. Clinical Features / Symptoms

Symptoms

  • PIP joint-এ ব্যথা ও swelling
  • আঙুলের middle joint পুরো সোজা করতে না পারা
  • আঙুল দেখতে “buttonhole”/বাঁকা আকৃতির
  • DIP joint অস্বাভাবিকভাবে সোজা বা hyperextended
  • Grip করতে সমস্যা
  • Fine motor কাজ যেমন writing, buttoning, typing-এ difficulty
  • আঘাতের পর প্রথমে শুধু pain/swelling থাকতে পারে, deformity পরে clearly দেখা যায়

Signs

  • PIP flexion deformity
  • DIP hyperextension
  • PIP extension weakness
  • Tenderness over dorsal PIP joint
  • Chronic হলে fixed contracture/stiffness

4. Clinical Diagnosis

History

  • Injury কীভাবে হয়েছে: jammed finger, sports trauma, cut injury, dislocation
  • Injury কতদিন আগের
  • Open wound আছে কি না
  • RA symptoms আছে কি না: morning stiffness, symmetrical small joint pain, swelling

Examination

A. Look

  • PIP flexed?
  • DIP hyperextended?
  • Swelling, wound, scar, redness আছে কি?

B. Feel

  • Dorsal PIP tenderness
  • Gap/defect over central slip area
  • Warmth/redness → infection/inflammatory arthritis ভাবতে হবে

C. Move

  • Active PIP extension test
  • Passive correction possible কি না
    • Passive correction possible হলে flexible deformity
    • Passive correction না হলে fixed/chronic contracture

Specific clinical test — Elson test

Elson test central slip injury detect করার সবচেয়ে useful clinical test। Test-এ PIP joint 90° flex করে table edge-এ রেখে middle phalanx extend করতে বলা হয়; central slip injury থাকলে PIP extension weak হয় এবং DIP rigid/extended অনুভূত হয়।

5. Investigations

1. X-ray finger — AP, lateral, oblique view

করতে হবে যদি:

  • Trauma history থাকে
  • Avulsion fracture suspicion থাকে
  • PIP dislocation suspicion থাকে
  • Chronic deformity থাকে
  • Surgery planning দরকার হয়

2. Ultrasound

  • Dynamic tendon continuity দেখা যায়
  • Central slip tear সন্দেহ হলে useful
  • Operator dependent

3. MRI

  • Unclear tendon injury
  • Chronic soft tissue assessment
  • Surgery planning

4. RA suspected হলে

  • CBC, ESR, CRP
  • RF, anti-CCP
  • Hand/wrist X-ray
  • Rheumatology assessment

6. Differential Diagnosis

  • Swan-neck deformity — PIP hyperextension + DIP flexion; Boutonniere-এর opposite pattern
  • Mallet finger — DIP flexion deformity due to terminal extensor injury
  • PIP joint dislocation
  • Trigger finger
  • Dupuytren contracture
  • Camptodactyly
  • Arthritic PIP contracture
  • Extensor tendon laceration — zone III injury

7. Complications

  • Permanent PIP flexion contracture
  • DIP hyperextension deformity
  • Finger stiffness
  • Grip weakness
  • Chronic pain
  • Loss of fine motor function
  • Recurrent deformity after treatment
  • Post-traumatic arthritis
  • Open injury হলে infection/tendon adhesion
  • RA হলে progressive joint destruction

8. Management / Treatment — Guideline-based

A. Non-pharmacological definitive treatment

Acute closed injury — no fracture/no open wound

  • PIP joint full extension splint
  • DIP joint free রাখতে হবে যাতে fingertip flexion exercise করা যায়
  • সাধারণত 4–8 weeks continuous splinting দরকার হয়; BSSH বলেছে stubbing injuries splintage দিয়ে treat করা হয় এবং splint সাধারণত 4–8 weeks পরা হয়।
  • Hand therapist follow-up জরুরি
  • Splint খুলে গেলে tendon healing নষ্ট হতে পারে

Exercise

  • Splint চলাকালীন DIP flexion exercise
  • পরে gradual PIP ROM
  • Grip strengthening late phase-এ

B. Surgical treatment — কখন লাগবে

Surgery consider করতে হবে যদি:

  • Open cut/laceration করে tendon কেটে যায়
  • Displaced avulsion fracture থাকে
  • Delayed presentation >4 weeks
  • Non-operative treatment fail করে
  • Fixed deformity/contracture থাকে
  • Rheumatoid arthritis associated severe deformity থাকে

StatPearls surgical indication হিসেবে delayed presentation beyond 4 weeks, associated laceration, displaced avulsion fracture, underlying RA বা failed conservative treatment উল্লেখ করেছে।

9. Pharmacological Treatment — Bangladesh Prescription Style

Dose note: নিচের dose adult, non-pregnant patient, normal kidney/liver function ধরে লেখা। NSAID একসাথে একাধিক দেওয়া যাবে না। Gastric ulcer, CKD, anticoagulant use, uncontrolled HTN, heart disease, asthma-sensitive NSAID patient-এ caution/avoid.

1) Paracetamol — Pain control

  • Generic name: Paracetamol
  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Non-opioid analgesic; para-aminophenol derivative
  • Why used: Mild to moderate pain কমাতে; tendon deformity ঠিক করে না
  • Adult dose: 500 mg 6–8 hourly PRN
  • Maximum: সাধারণত 3–4 g/day; liver disease/alcohol use থাকলে কম dose
  • Duration: 3–5 days or as needed
  • Bangladesh available brands: Ace 500 mg, Renova 500 mg, Paragesic 500 mg, Tamen XR 665 mg; MedEx-এ Ace 500 mg paracetamol tablet হিসেবে listed আছে এবং pain indications উল্লেখ আছে। MedEx paracetamol brand list-এ Renova 500 mg, Paragesic 500 mg, Tamen XR 665 mg-ও listed।
  • Side effects: nausea, rash, hepatotoxicity in overdose
  • Important interaction: alcohol, warfarin with prolonged regular use, other paracetamol-containing combination products

2) Ibuprofen — Pain + inflammation

  • Generic name: Ibuprofen
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; non-selective COX inhibitor
  • Why used: Acute injury-related pain/swelling কমাতে
  • Adult dose: 200–400 mg every 6–8 hours after meal PRN
  • Maximum OTC style: 1200 mg/day; MedEx ibuprofen adult pain dose 200–400 mg 3–4 times/day এবং max 1200 mg/day উল্লেখ করেছে।
  • Duration: 3–5 days
  • Bangladesh available brands: Profen 400 mg, Rapofen 400 mg, Rebufen 400 mg — MedEx-এ listed।
  • Side effects: gastritis, dyspepsia, GI bleeding, renal impairment, fluid retention, BP rise
  • Interactions: anticoagulants/antiplatelets, steroids, SSRIs, ACEi/ARB + diuretic, lithium, methotrexate
  • Avoid: active peptic ulcer, severe CKD, NSAID-induced asthma, late pregnancy

3) Naproxen — Longer acting NSAID

  • Generic name: Naproxen / Naproxen sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; non-selective COX inhibitor
  • Why used: Pain + swelling; dosing less frequent
  • Adult dose: 250–500 mg twice daily after meal
  • Maximum: 1000 mg/day; MedEx naproxen dose for inflammatory joint disease 500–1000 mg/day in two divided doses and max 1000 mg/day mentioned।
  • Duration: 3–5 days for acute injury pain
  • Bangladesh available brands: Naproxin 250/500 mg, Naproxen 500 mg, Pairox 250/500 mg, Proxen 500 mg, Novaxen 500 mg — MedEx-এ listed।
  • Side effects: gastritis, ulcer bleeding, renal impairment, edema, dizziness
  • Interactions: anticoagulants, aspirin, steroids, SSRIs, ACEi/ARB/diuretics, lithium, methotrexate
  • Clinical note: Ibuprofen/naproxen/diclofenac—একসাথে নয়; যেকোনো একটি NSAID বেছে নিতে হয়

4) Diclofenac oral — Stronger pain/inflammation relief

  • Generic name: Diclofenac sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative; COX inhibitor
  • Why used: More painful inflammatory injury হলে short course
  • Adult dose: 50 mg 2–3 times daily after meal
  • Maximum: 150 mg/day; MedEx diclofenac adult max daily dose 150 mg উল্লেখ করেছে।
  • Duration: 3–5 days
  • Bangladesh available brands: Diclofen 50 mg, Diclovir 50 mg, Difenac 50 mg, Dilock 50 mg, Rispain 50 mg — MedEx-এ listed।
  • Side effects: gastritis, ulcer, renal dysfunction, liver enzyme elevation, edema, BP rise, cardiovascular risk
  • Interactions: diclofenac lithium/digoxin level বাড়াতে পারে; anticoagulant bleeding risk, quinolone + NSAID seizure risk, steroid/other NSAID দিলে adverse effect বাড়ে—MedEx interaction section-এ উল্লেখ আছে।
  • Avoid/caution: ischemic heart disease, CKD, active ulcer, anticoagulant use

5) Diclofenac gel — Local pain relief

  • Generic name: Diclofenac sodium topical gel
  • Therapeutic category: Topical analgesic, anti-inflammatory
  • Pharmacological class: Topical NSAID
  • Why used: Local finger pain/swelling কমাতে, systemic NSAID risk কম
  • Dose: 1% gel affected area-তে thin layer; MedEx অনুযায়ী 2–4 g 3–4 times daily apply করা যায়।
  • Duration: 5–7 days
  • Bangladesh available brands: Diclofen gel 1%, Erdon gel 1%, Fastfit gel 1%, Fengel gel 1%, Volinac gel 1% — MedEx diclofenac topical brands listed।
  • Side effects: local irritation, rash, burning sensation
  • Avoid: open wound/laceration-এর উপর লাগানো যাবে না

6) Pantoprazole — NSAID gastric protection

  • Generic name: Pantoprazole sodium
  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: Proton pump inhibitor
  • Why used: NSAID দিলে gastritis/ulcer risk কমাতে, especially high-risk patient
  • Adult dose: 20–40 mg once daily before breakfast
  • Duration: যতদিন NSAID চলছে বা high-risk হলে clinician judgment অনুযায়ী
  • MedEx pantoprazole NSAID-induced ulcer prevention-এ 20 mg once daily উল্লেখ করেছে।
  • Bangladesh available brands: Pantrol 20/40 mg, Panzer 20/40 mg, Panzol 20/40 mg — MedEx-এ listed।
  • Side effects: headache, diarrhea, abdominal discomfort; long-term use-এ B12 deficiency, hypomagnesemia, osteoporosis risk
  • Interactions: generally low; long-term unnecessary use avoid

7) Antibiotic — Only open cut/contaminated wound/infection হলে

Important

Closed Boutonniere injury-তে routine antibiotic লাগে না। Antibiotic only:

  • Open laceration
  • Contaminated wound
  • Cellulitis
  • Post-operative surgeon advice
  • Bite injury হলে separate protocol

Option A: Amoxicillin + Clavulanic acid

  • Generic name: Amoxicillin + Clavulanic acid
  • Therapeutic category: Antibacterial
  • Pharmacological class: Aminopenicillin + beta-lactamase inhibitor
  • Why used: Open contaminated soft tissue wound infection prophylaxis/treatment
  • Adult dose: 625 mg 12 hourly or 8 hourly depending severity/local protocol
  • Duration: commonly 5 days; severe infection হলে surgeon/ID advice
  • Bangladesh available brands: Avloclav 500+125 mg, Bioclavid 500+125 mg/875+125 mg, Clamox 500+125 mg/875+125 mg, Clavoxil 500+125 mg, Tyclav 875+125 mg — MedEx-এ listed।
  • Side effects: diarrhea, nausea, rash, candidiasis, cholestatic hepatitis rare
  • Interactions: warfarin INR rise, allopurinol rash risk, methotrexate toxicity risk

Option B: Cephalexin

  • Generic name: Cephalexin
  • Therapeutic category: Antibacterial
  • Pharmacological class: 1st generation cephalosporin
  • Why used: Skin/soft tissue infection due to staph/strep; MedEx cephalexin skin and soft tissue infection indication উল্লেখ করেছে।
  • Adult dose: 500 mg 6 hourly or 12 hourly depending severity
  • Duration: commonly 5–7 days
  • Bangladesh available brands: Acelex 500 mg, Cefalex 500 mg, Cephalen 500 mg, Ceporal 500 mg, Selex 500 mg — MedEx-এ listed।
  • Side effects: diarrhea, nausea, rash, allergy
  • Interactions: warfarin effect may increase; probenecid increases level
  • Avoid: severe beta-lactam allergy

8) RA-associated Boutonniere deformity — Disease control medicine

RA থাকলে শুধুমাত্র splint দিলে long-term deformity progression থামবে না; RA control দরকার। ACR RA guideline DMARD therapy নিয়ে recommendations দিয়েছে, এবং methotrexate inflammatory arthritis management-এ central drug হিসেবে ব্যবহৃত হয়।

Methotrexate — Rheumatologist-supervised

  • Generic name: Methotrexate
  • Therapeutic category: DMARD
  • Pharmacological class: Antimetabolite; folate antagonist
  • Why used: RA disease activity control; tendon/joint destruction কমাতে
  • Adult RA dose: 7.5 mg once weekly; titrate commonly 15–20 mg once weekly under specialist monitoring
  • MedEx adult rheumatoid arthritis dose single 7.5 mg once weekly, maximum 20 mg/week উল্লেখ করেছে।
  • Bangladesh available brands: Meth 2.5 mg, Methotrax 2.5/10/15 mg, Mtrex 2.5/10 mg, MTX 2.5 mg, Trexonate 2.5/10 mg — MedEx-এ listed।
  • Side effects: nausea, mouth ulcer, hepatotoxicity, bone marrow suppression, pneumonitis, teratogenicity
  • Monitoring: CBC, ALT/AST, creatinine; pregnancy test where relevant
  • Interactions: NSAIDs, TMP-SMX, penicillins, alcohol, phenytoin, sulfasalazine; MedEx methotrexate interaction section NSAIDs এবং hepatotoxicity risk উল্লেখ করেছে।
  • Contraindication: pregnancy, severe liver disease, significant renal impairment, active serious infection

Folic acid with Methotrexate

  • Generic name: Folic acid
  • Therapeutic category: Vitamin
  • Pharmacological class: Water-soluble B vitamin
  • Why used: Methotrexate side effect যেমন mouth ulcer, GI upset, liver enzyme rise কমাতে
  • Common dose: 5 mg once weekly on non-methotrexate day or per rheumatologist
  • MedEx folic acid 5 mg adult dosing listed করেছে।
  • Bangladesh available brands: Folac 5 mg, Folic Acid 5 mg, Folic-Son 5 mg, Folus 5 mg — MedEx-এ listed।
  • Side effects: rare GI upset, rash
  • Interaction: generally minimal

10. Bangladesh doctors commonly prescribe — practical list

Boutonniere deformity closed injury হলে সাধারণ prescription pattern:

  1. PIP extension splint + hand therapy — main treatment
  2. Paracetamol 500 mg TDS/PRN 3–5 days — mild pain
  3. One NSAID only:
    • Ibuprofen 400 mg TDS 3–5 days or
    • Naproxen 250/500 mg BD 3–5 days or
    • Diclofenac 50 mg BD/TDS 3–5 days
  4. Pantoprazole 20/40 mg OD — NSAID gastric protection if needed
  5. Diclofenac gel 1% local application — local pain/swelling, no open wound
  6. Antibiotic only open wound/infection হলে — amoxicillin-clavulanate or cephalexin as clinically indicated
  7. RA patient হলে rheumatologist referral + DMARD — methotrexate ± folic acid, monitoring সহ

11. Prevention

  • Finger sports injury হলে early assessment
  • Jammed finger হলে “just sprain” ধরে ignore না করা
  • PIP joint pain/swelling + extension weakness থাকলে early Elson test
  • Early splinting: PIP straight, DIP free
  • Splint নিজে খুলে বারবার bend করা যাবে না
  • Open cut হলে wound wash, sterile dressing, tetanus status check, urgent hand surgeon referral
  • RA থাকলে disease control, regular rheumatology follow-up
  • Hand therapy exercise properly follow করা

12. Overview / Summary

Boutonniere deformity হলো central slip extensor tendon injury-এর কারণে হওয়া deformity যেখানে PIP flexion + DIP hyperextension দেখা যায়। Diagnosis mainly clinical, especially Elson test, এবং trauma হলে X-ray জরুরি। Main treatment হলো PIP extension splint 4–8 weeks, hand therapy এবং selected case-এ surgery। ওষুধ deformity ঠিক করে না—pain, inflammation, infection বা RA control-এর জন্য ব্যবহৃত হয়।

13. Actionable Plan / Steps

  1. Acute injury হলে same day finger X-ray করুন।
  2. Elson test করুন central slip injury confirm/suspect করার জন্য।
  3. PIP extension splint দিন, DIP free রাখুন।
  4. Hand surgeon/orthopedic referral করুন যদি open wound, fracture, dislocation, delayed >4 weeks, fixed deformity বা failed splint থাকে।
  5. Pain হলে paracetamol ± one NSAID short course দিন; NSAID risk থাকলে avoid/modify করুন।
  6. RA suspected হলে RF, anti-CCP, ESR/CRP করে rheumatology referral দিন।
  7. Patient-কে clearly বলুন: splint compliance না থাকলে permanent deformity হতে পারে।

14. Reference List — Textbook + Guideline + DOI

Textbooks

  1. Apley & Solomon’s System of Orthopaedics and Trauma, latest ed., Hand injuries/extensor tendon injury section.
  2. Green’s Operative Hand Surgery, latest ed., Extensor tendon injuries and boutonniere deformity chapter.
  3. Campbell’s Operative Orthopaedics, latest ed., Hand tendon injuries section.
  4. Robbins & Cotran Pathologic Basis of Disease, latest ed., rheumatoid arthritis pathogenesis section.
  5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, latest ed., NSAIDs and DMARDs chapters.
  6. Katzung Basic & Clinical Pharmacology, latest ed., NSAIDs, glucocorticoids, DMARDs chapters.

Guidelines / Clinical resources

  1. AAOS OrthoInfo — Boutonnière Deformity: splinting and DIP movement guidance.
  2. British Society for Surgery of the Hand — Boutonniere injury: splintage 4–8 weeks and tendon repair in cut injury.
  3. 2021 American College of Rheumatology Guideline for Treatment of Rheumatoid Arthritis — DOI: 10.1002/acr.24596.
  4. EULAR RA management recommendations 2022 update — DOI: 10.1136/ard-2022-223356.

Peer-reviewed DOI

  1. Lee JK et al. Anatomic repair of the central slip with anchor suture augmentation in chronic boutonniere deformity. DOI: 10.4055/cios20170.
  2. Boyes JH / central slip tenodesis diagnostic literature: Central slip tenodesis test for early diagnosis of potential boutonniere deformity. DOI: 10.1016/0266-7681(94)90057-4.

Md.Rafiqul Islam Lipu,Date:-23-06-2026 Tuesday,Time:-11-47-12 Am

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