The Use of Relative Motion Flexion Orthoses for Chronic Boutonniere Deformity

Published:October 04, 2022DOI:


      This study investigated the effectiveness of a relative motion flexion orthosis (RMFO) for increasing the range of motion for boutonniere deformity.


      We included 28 patients aged 13–62 years with chronic boutonniere deformity who could complete 0° proximal interphalangeal (PIP) joint extension with the pencil test and were stage 1 according to the Burton classification of boutonniere deformity. At the initial hand therapy appointment, the RMFO was made. The duration of the orthosis usage at the initial therapy session, after stopping the use of the orthosis (posttreatment), and at the follow-up period were noted.


      The mean time for orthosis usage of all patients was 11.7 weeks (6–40 weeks). The mean initial active distal interphalangeal joint flexion was 47° (0° to 90°) and improved to 66.8° (5° to 110°). The mean initial extension lag of the PIP joint was 22.5° (5° to 55°) and improved to 12° (0° to 30°). This did not change between discontinuation of the orthosis and final follow-up.


      The use of RMFO is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity.

      Type of study/level of evıdence

      Therapeutic IV.

      Key words

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        • Merritt W.H.
        • Jarrell K.
        A paradigm shift in managing acute and chronic boutonniere deformity: Anatomic rationale and early clinical results for the relative motion concept permitting immediate active motion and hand use.
        Ann Plast Surg. 2020; 84: S141-S150
        • Schreuders T.A.
        • Van Strien G.
        40 State of the art of extensor tendon rehabilitation.
        Tendon Surgery of the Hand: Expert Consult-Online and Print. 2012; : 427
        • McKeon K.E.
        • Lee D.H.
        Posttraumatic boutonnière and swan neck deformities.
        J Am Acad Orthop Surg. 2015; 23: 623-632
        • Bellemère P.
        Treatment of chronic extensor tendons lesions of the fingers.
        Chir Main. 2015; 34: 155-181
        • Evans R.B.
        Clinical management of extensor tendon injuries: the therapist’s perspective.
        in: Skirven T. Osterman A.L. Fedorczyk J. Amadio P. Rehabilitation of the Hand and Upper Extremity. Elsevier Mosby, 2011: 521-554
        • Evans R.B.
        Managing the injured tendon: current concepts.
        J Hand Ther. 2012; 25: 173-190
        • Duzgun S.
        • Duran A.
        • Keskin E.
        • Yigit A.K.
        • Buyukdogan H.
        Chronic boutonniere deformity: cross-lateral band technique using palmaris longus autograft.
        J Hand Surg. 2017; 42: 661.e1-661.e5
        • Merritt W.H.
        • Wong A.L.
        • Lalonde D.H.
        Recent developments are changing extensor tendon management.
        Plast Reconstr Surg. 2020; 145: 617e-628e
        • Lalonde D.
        • Lee S.
        • van Strien G.
        PIP Central Slip and Fracture: Many Different Approaches. 2016.
        • Hirth M.J.
        • Howell J.W.
        • O'Brien L.
        Relative motion orthoses in the management of various hand conditions: A scoping review.
        J Hand Ther. 2016; 29: 405-432
        • Lalonde D.H.
        • Flewelling L.A.
        Solving hand/finger pain problems with the pencil test and relative motion splinting.
        Plast Reconstr Surg Glob Open. 2017; 5: e1537
        • Burton R.
        Extensor tendons. Late reconstruction.
        in: Green D.P. Lampert R. Kozin S.H. Green's Operative Hand Surgery. 4th ed. Churchill Livingstone, 1999: 1988-2021
        • Merritt W.H.
        Relative motion splint: active motion after extensor tendon injury and repair.
        J Hand Surg Am. 2014; 39: 1187-1194
        • Rosenthal R.
        Parametric measures of effect size.
        in: Cooper H. Hedges L.V. Valentine J.C. The Handbook of Research Synthesis. Russell Sage Foundation, 1994: 231-244
        • Field A.
        Discovering Statistics Using SPSS.
        SAGE Publications, 2009: 550
        • Faul F.
        • Erdfelder E.
        • Lang A.G.
        • et al.
        ∗Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Methods. 2007; 39: 175-191
        • Lenhard W.
        • Lenhard A.
        Computation of Effect Sizes. Psychometrica, 2016.
        • Hayran M.
        Spearman Testi.
        Sağlık Araştırmaları için Temel İstatistik. 1st ed. Omega Araştırma, Ankara2011: 325-332
        • Johnson C.
        • Swanson M.
        • Manolopoulos K.
        Treatment of a zone III extensor tendon injury using a single relative motion with dorsal hood orthosis and a modified short arc motion protocol-A case report.
        J Hand Ther. 2021; 34: 135-141
        • Merritt W.H.
        • Howell J.W.
        Relative motion concepts: applied to hand therapy management of finger extensor tendon zones III-VII repairs, acute and chronic boutonniere deformity and sagittal band injury.
        in: Rehabilitation of the Hand and Upper Extremity. 7th edition. Elsevier, 2021
        • Strickland J.W.
        • Glogovac S.V.
        Digital function following flexor tendon repair in zone II: a comparison of immobilization and controlled passive motion techniques.
        J Hand Surg Am. 1980; 5: 537-543