Houston Methodist. Leading Medicine

Hand FAQ

Question:

My sweet grandma has the start of old-people's bony, gnarled knuckles. Her fingers are starting to get stuck like that. She insists that nothing can be done to help. I'm taking some liberties by asking around about what can be done for this problem?

Answer:

People who have rheumatoid arthritis of the hands often develop a finger deformity referred to as a Boutonniere deformity. The name comes from a French word for "button hole". We will explain that further after we describe the deformity. When the affected finger is viewed from the side, it has a zig-zag appearance. That's because the joint of the middle knuckle of the finger (called the proximal interphalangeal or PIP joint) is permanently bent toward the palm while the tip of the finger (as the distal interphalangeal or DIP joint) is bent back or hyperextended. This flexion deformity of the middle joint (the proximal interphalangeal or PIP joint) occurs when the central slip of the extensor tendon separates. The head of the proximal phalanx (middle finger) bone literally pops through the gap. It's like a finger through a button hole and thus the name boutonniere. The tip of the finger is then drawn into hyperextension because the two slips of the extensor tendon on either side of the separated central tendon are stretched by the head of the proximal phalanx. The two peripheral slips attach to the distal phalanx (finger tip bone), while the proximal slip is inserted into the middle phalanx. This deformity makes it difficult or impossible to extend the proximal interphalangeal (PIP) joint and bend the finger tip. You can imagine how difficult it is to perform daily activities that require flexibility of the fingers. Try picking anything up with your fingers stuck in a Boutonniere position. Better yet, try using a key to unlock a door or turn a door knob. You will probably have to put anything down you are carrying and use two hands together. What can be done about this problem? Treatment depends on how severe the deformity is, how much motion there is at each joint, and whether or not the joint can be passively straightened. Fingers that can be stretched or moved back to their normal resting position may benefit from hand therapy. The hand therapist will use splinting, exercises, and specific therapeutic activities to help patients regain lost motion and maximize function. But fingers that are in a Boutonniere position and can't be moved to a normal position are considered contracted. Surgery becomes the only option at that point. Studies show that results of surgery are best when the procedures are done before the deformities become fixed contractures. Anything you can do to encourage your grandmother to get professional help (at least an opinon) would be a step in the right direction. Your concern, support, and efforts on her behalf may be what help her see things differently. Keoni Williams, MD, and Andrew L. Terrono, MD. Treatment of Boutonniere Finger Deformity in Rheumatoid Arthritis. In The Journal of Hand Surgery. August 2011. Vol. 36A. No. 8. Pp. 1388-1393.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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