I. Mild extension lag, passively correctable
II. Moderate extension lag, passively correctable
III. Mild flexion contracture
IV. Advanced flexion contracture
Conservative treatment involves continuous extension splinting of the PIP joint and progressive flexion splinting with active flexion of the DIP joint. Splinting must be continuous and the patient must be very attentive to splinting techniques and not remove the splint during the treatment period of two to three months. In selected cases, the PIP joint may be stabilized with a temporary transarticular pin. This has known risks including infection, hardware complications, numbness and others and requires a second procedure to remove the pin. Despite the best efforts, there is usually some residual boutonniere posture. The treatment of long standing or fixed boutonniere deformity requires therapy to restore full passive motion of all joints prior to any surgery. If passive motion cannot be achieved, surgical results of tendon reconstruction are often poor, and proximal interphalangeal joint fusion may be indicated. Surgical reconstruction is technically demanding, involving tenotomy and transfer of tendon slips. Therapy is necessary for several months after surgery. Stiffness and residual contracture usually persists to some degree even after surgery. For this reason, nonoperative treatment is often a reasonable option.
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