› Burton classification for staging boutonniere deformity
› Stage 1
› PIP extension lag present
› Passively correctable to full extension
› Nonoperative management appropriate
› Stage 2
› Fixed PIP flexion contracture
› Preserved joint surfaces on imaging
› Serial casting or operative consideration
› Stage 3
› Fixed contracture with joint surface destruction
› Operative reconstruction required
› Severity stratification for disposition
› Closed passively correctable
› Nonoperative splinting pathway
› Open injury or fracture
› Surgical referral pathway
› Fixed deformity at presentation
› Delayed or chronic injury — complex management
› MRI indications and role
› Acute utility is limited
› Diagnosis is primarily clinical and radiographic
› Availability and time constraints
› Problem-solving indications
› Equivocal Elson test with high clinical suspicion
› Preoperative planning for complex or chronic deformity
› Suspected partial tear vs complete disruption
› MRI findings in central slip injury
› Discontinuity or signal change at central slip insertion
› Peritendinous edema over dorsal PIP
› Contraindications
› Metallic implants incompatible with MRI
› Patient instability (not relevant in isolated boutonniere)
› CT indications
› Fracture characterization when plain radiographs equivocal
› Avulsion fragment size quantification
› Articular involvement assessment — >30% articular surface threshold for surgery
› Fracture-dislocation complex injury
› PIP joint alignment assessment
› Comminution pattern for operative planning
› CT findings
› Fragment size and displacement at central slip insertion
› Joint congruence assessment
› Limitations
› Soft tissue detail inferior to MRI
› Radiation dose consideration in young athletes
› Ultrasound for central slip assessment
› Can detect central slip disruption with high sensitivity and specificity in experienced hands
› Operator dependent
› High-frequency probe required (15 MHz or higher)
› Dynamic assessment advantage
› Real-time visualization during Elson test equivalent maneuver
› Tendon continuity and gap assessment
› Ultrasound findings
› Central slip discontinuity or defect
› Hematoma over dorsal PIP
› Lateral band position assessment
› Role in clinical practice
› Adjunct when clinical exam equivocal
› Guidance for aspiration of peritendinous hematoma if needed
› Standard radiographs — first-line imaging
› Views required
› AP of affected finger
› True lateral of affected finger
› Oblique of affected finger
› Findings to assess
› Avulsion fracture at base of middle phalanx — central slip insertion
› PIP joint subluxation or dislocation
› Associated proximal or middle phalanx fractures
› Normal radiographs common in closed soft tissue injuries
› Clinical diagnosis remains primary
› Negative X-ray does not exclude central slip disruption
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