Initially, full passive PIP extension and DIP flexion past 0 degrees must be achieved with dynamic or static splinting or cylinder serial casting. Once full or maximum passive PIP extension is achieved, the patient is treated as for an acute injury.
The following management is indicated for patients who do not have a full supple passive range of motion with a boutonniere deformity. These patients may have splint pressure related problems and may require percutaneous pinning of their PIP joints. The therapy requirements here are variable depending on the degree of difficulty with splinting and possible skin breakdown problems.
When first seen:
A four point boutonniere splint is fabricated maintaining the PIP joint is maximum available extension and the DIP joint in maximum available flexion.
The splint is sequentially adjusted to increase DIP flexion and when that is maximized to increase PIP extension.
Active DIP flexion exercises are initiated hourly until full active DIP flexion is obtained.
Thermoplastic splints may give problems with skin breakdown, and plaster cylinder casts are often preferable.
The duration of splinting must be tailored according to the patient's progress and may require several months of progressive splinting.
This splinting program is always indicated preoperatively to maximize preoperative range of motion and improve suppleness of the soft tissues. In many cases this will obviate the need for surgical intervention.
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