Musculoaponeurotic architecture of the human masseter muscle: an in vivo ultrasonographic study of architectural changes during mandibular protrusion and lateral excursions.

OBJECTIVE: The present study evaluated the in vivo musculoaponeurotic architecture of the superficial head (SH) of the masseter muscle (MM) of asymptomatic participants in excursive mandibular movements compared to the relaxed state as examined with ultrasonography. It was hypothesized that the mean fiber bundle length (FBL) and mean height of the aponeurosis (HA) of the laminae of the SH would differ significantly between the relaxed state and protrusion, ipsilateral excursion, and contralateral excursion. STUDY DESIGN: The MM was studied volumetrically in 12 female and 12 male asymptomatic participants bilaterally by using ultrasound imaging. Mean FBL and HA in protrusion and ipsilateral and contralateral excursion were compared to these values in the relaxed state using paired t tests (P < .05). The intraclass correlation coefficient was used to assess intraexaminer reliability. RESULTS: The SH exhibited multiple laminae. Fiber bundles were found to attach to bone and the superior and inferior aponeuroses. Mean FBL was significantly shorter and mean HA significantly longer in protrusion and the excursions than in the relaxed state although the pattern of altered laminae and aponeuroses differed among the mandibular movements. Intraexaminer reliability was excellent. CONCLUSION: Specific changes in mean FBL and mean HA suggest differential contraction of the SH of the MM based on laminar morphology. These findings provide a baseline to investigate musculoaponeurotic changes in patients with myogenic masseter muscle pain.

Chronic changes in muscle architecture and aponeurosis structure following calf muscle strain injuries.

BACKGROUND: Muscle strain injuries in the human calf muscles are frequent sports injuries with high recurrence. Potential structural and functional changes in the medial head of the musculus gastrocnemius (GM) and the associated aponeurosis are not well documented. PURPOSE: To test whether a GM muscle strain injury affects muscle fascicle length, pennation angle, and the morphology of the deep aponeurosis at rest and during muscle contraction long time after the injury. Additionally, electromyography (EMG) of the GM and the soleus muscle during a unilateral heel rise was measured in the injured and uninjured calf. METHODS: GM fascicle length, pennation angle, and aponeurosis thickness was analyzed on dynamic ultrasonography (US) recordings in 10 participants with a chronic calf strain. In addition, US images taken across the distal portion and mid-belly of the GM were analyzed at three different ankle positions. EMG recordings were obtained during a unilateral heel rise. RESULTS: The pennation angle of the injured distal GM was significantly larger compared to the uninjured GM in the contracted, but not the relaxed state. Pennation angle increased more in the injured compared to the uninjured GM during contraction. Fascicle length was shorter in the most distal portion of the injured GM. Fascicles at the distal portion of the injured GM showed a pronounced curvilinear shape as the muscle contracted and the aponeurosis was enlarged in the injured compared to the uninjured GM. The ratio between GM and soleus EMG activity showed a significantly higher relative soleus activity in the injured compared to the healthy calf. CONCLUSION: The greater change in pennation angle and curvilinear fascicle shape during contraction suggest that a long-term consequence after a muscle strain injury is that some muscle fibers at the distal GM are not actively engaged. The significantly enlarged aponeurosis indicates a substantial and long-lasting connective tissue involvement following strain injuries.

Site-specific features of active muscle stiffness and proximal aponeurosis strain in biceps femoris long head.

Limited information is available on site-specific features of muscle stiffness and aponeurosis strain of the biceps femoris long head (BFlh) during contractions. Therefore, understanding of the mechanics and etiology of hamstring strain injuries remains difficult. As a first step to gain further insight into them, the present study aimed to identify whether active muscle stiffness and proximal aponeurosis strain during contractions are varied along the long axis of the BFlh. The BFlh muscle shear wave speed (proxy for stiffness) was measured in the proximal, central, and distal sites during 20%, 50%, and 80% of maximal voluntary isometric contraction (MVC) of knee flexion exerted with the hip and knee joints flexed at 40° and 30°, respectively, using ultrasound shear wave elastography. Further, a segmental strain of the BFlh proximal aponeurosis was assessed in the proximal, central, and distal sites during isometric knee flexion, using B-mode ultrasonography. The shear wave speed was significantly higher in the distal site than the proximal and central sites at 20% MVC (p ≤ .002, with a large effect size), whereas no significant difference was found between the three sites at 50% and 80% MVC. The BFlh proximal aponeurosis strain showed no significant difference between the proximal, central, and distal sites at any contraction intensity. These findings indicate that site-specific differences in muscle stiffness and proximal aponeurosis strain are substantially small and that muscle stiffness and proximal aponeurosis strain of the BFlh at moderate-to-high contraction intensity is not exceptional in the site where a sprinting-type hamstring strain typically occurs.

The architecture of the 6-month-old gastrocnemius: a 3D volumetric study

Gastrocnemius is essential in normal gait, contributing to the control of ankle plantar flexion and knee flexion. However, there is a paucity of literature on the architecture of the infant gastrocnemius muscle prior to the onset of weight-bearing and gait. This study investigates the three-dimensional (3D) musculoaponeurotic architecture of the gastrocnemius in a six-month-old infant. One six-month-old cadaver was used in this study (The University of Toronto Health Sciences Research Ethics Board, #32679, and The University of Auckland Human Participants Ethics Committee, #016164). Medial (MG) and lateral (LG) heads of the gastrocnemius were serially dissected and a Microscribe G2X(TM) digitizer used to digitize fiber bundles, aponeuroses and tendons. Data were then exported to Autodesk(R) Maya(R) to create 3D models. Custom software quantified architectural parameters, including fiber bundle length, pennation angle, physiological cross-sectional area, and muscle volume. The intramuscular architecture was assessed to determine whether musculoapo-neurotic partitions were present. Muscle volume was <1cm3 for both MG and LG. Three architectural partitions, proximal, middle, and distal, were identified for both MG and LG. Notably, the proximal partitions of both MG and LG had mean fiber bundle length at 2.21 ± 0.41 cm and 2.22 ± 0.27 cm, significantly greater (p < 0.05) than the middle and the distal partitions. The results of this study suggest that both MG and LG have architectural partitions before the commencement of gait. Further longitudinal studies with larger sample sizes are needed to confirm the presence of these architectural partitions, as well as to investigate their growth across the developmental spectrum

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Age-related differences in vastus lateralis fascicle behavior during fast accelerative leg-extension movements.

Leg-extensor rate of power development (RPD) decreases during aging. This study aimed to identify the underlying mechanism of the age-related decline in RPD during a fast acceleration in terms of in vivo vastus lateralis (VL) fascicle shortening behavior. Thirty-nine men aged between 25 and 69 years performed three maximal isokinetic leg-extensor tests with a fixed initial acceleration of 45° knee extension in 150 ms until 340°/s knee angular velocity. RPD, VL activity, and ultrasound images were recorded to assess (relative) fascicle shortening and mean shortening velocity for the phases of electromechanical delay, pretension, and acceleration. Our findings show that fascicle shortening and mean shortening velocity during a fast action increase with aging (0.002 per year, P = .035 and 0.005 s-1 per year, P = .097, respectively), mainly due to a higher amount of shortening in the phase of electromechanical delay. The ratio of VL fascicle length over upper leg length at rest showed a negative correlation (r = -.46, P = .004) with RPD/body mass, while pennation angle at rest showed a trend toward a positive correlation (r = .28, P = .089). To conclude, our findings indicate that the ability to reach high VL fascicle shortening velocities in vivo is not reduced in older men while performing preprogrammed fast accelerations. The greater amount of fascicle shortening in old age is probably the result of age-related differences in the tendinous properties of the muscle-tendon complex, forcing the fascicles to shorten more in order to transmit the muscle force to the segment.

Abdominal wall morphometric variability based on computed tomography: Influence of age, gender, and body mass index.

INTRODUCTION: Ventral hernia surgery does not usually account for the individuality of the abdominal wall anatomy. This could be both because medical imaging is rarely performed before surgery and because data on abdominal wall variability are limited. The objective of the present study was to perform an exhaustive morphometric analysis of abdominal wall components based on computed tomography (CT) scans. MATERIALS AND METHODS: A retrospective study was performed on 120 abdominopelvic CT scans of clinically normal adults aged 18-86 years equally divided between women and men and into four age groups. Each abdominal wall muscle was evaluated in terms of area, thickness, shape ratio, fat infiltration, and aponeuroses width. The influence of age, gender, and body mass index (BMI) was investigated, as well as muscular asymmetry. RESULTS: The abdominal wall muscle area represented 8.5 ± 2.5% of the abdominal area. The internal oblique muscle had the largest area, the rectus abdominis was the thickest, the transversus abdominis was the narrowest and had the smallest area. The width of the linea alba was 20.3 ± 12.0 mm. The evolution of the abdominal wall with age was quantified, as well as the large differences between the sexes and BMI groups, resulting in strong correlations and highlighting the specific pattern of the transversus abdominis. The asymmetry of the left and right muscle areas oscillated around 17%. CONCLUSIONS: The various components of the abdominal wall have been precisely described. Knowledge of their variability could be used to enhance the planning of ventral hernia surgery or to develop numerical modeling of the abdominal wall.

Technical report: dynamic assessment of plantar fasciitis and plantar fascia tears utilising dorsiflexion of the great toe.

Discrimination between plantar fasciitis and partial tears of the plantar fascia can be difficult on ultrasound given laxity of the plantar fascia in the region of its calcaneal insertion and anisotropy. Dynamic assessment with great toe dorsiflexion can improve visualisation of the proximal portion of the plantar fascia on ultrasound, by straightening the plantar fascia due to the windlass mechanism. This article describes the technique and its anatomical basis.

Clinics in diagnostic imaging (195). Plantar fibromatosis.

A 46-year-old man presented with a six-month history of lumps in the sole of his left foot. Physical examination revealed two nodules, one tender and one firm, at the plantar left foot with no overlying skin changes. Although the initial radiographs were normal, magnetic resonance imaging of the left foot demonstrated two nodules along the medial band of the plantar fascia, characteristic of plantar fibromas. The patient opted for surgical excision. There was no further recurrence of symptoms after surgery. We describe the clinical and radiological features of plantar fibromatosis and briefly discuss other causes of lumps and pain in the sole of the foot.

Incidence and implications of fracture in core muscle injury.

OBJECTIVE: To determine the pubic bone fracture incidence and associated injury patterns in patients with core muscle injury. MATERIALS AND METHODS: Ninety-three consecutive patients with core muscle injury protocol MRI showing rectus abdominis-adductor longus aponeurotic plate injuries from June 2007 through August 2017 were independently analyzed in blinded fashion by two musculoskeletal radiologists for the presence or absence of pubic bone fracture. A variety of other osseous and soft tissue injury characteristics were recorded. Pain duration prior to MRI and return to play time were taken from the clinical record. Statistical analysis included fracture incidence as well as the association of fracture with other injury characteristics, duration of pain, and return to play time. RESULTS: Eighty-seven men and six women with a mean age of 34.4 years (range, 16-66 years) were included in the study cohort. Overall fracture incidence was 18.3% (17/93) including 13 fatigue fractures of the pubic body and four elevated cortical fractures/fragments. After correction for multiple comparisons, no strong association was identified with osseous or soft tissue injury characteristics, pain duration, or return to play time. CONCLUSIONS: Pubic fractures-particularly fatigue fractures-are a common co-existing injury in patients with a wide range of core muscle injury patterns. The presence of fracture did not have a strong correlation with injury patterns, pain duration, or return to play time but may have implications for patient management.

Intense Therapeutic Ultrasound for Treatment of Chronic Plantar Fasciitis: A Pivotal Study Exploring Efficacy, Safety, and Patient Tolerance.

Intense therapeutic ultrasound for chronic plantar fasciitis musculoskeletal tissue pain reduction was evaluated in a pivotal clinical trial examining effectiveness, safety, and patient tolerance. In this single-blinded study, 33 patients received 2 treatments that were 4 weeks apart on plantar fascia tissue along with conservative standard of care. Patients were followed for up to 6 months after the first treatment, receiving a physical examination and diagnostic ultrasound at each follow-up visit and completing patient-/subject-reported outcome measure and Foot Function Index surveys. The goal was to reduce overall pain by ≥25% on average and >25% individually. Hypoechoic area changes on diagnostic ultrasound and adverse events were measured. The percentage meeting pain reduction criteria at weeks 4, 8, 12, and 26 were 72%, 81%, 86%, and 79%, respectively. Mean pain scores at each visit were significantly different from baseline (p < .001) at -39%, -49%, -51%, and -44%. Hypoechoic lesions were found in all patients and decreased in size significantly (p < .05) at weeks 8 and 12 (-56% and -67%). Foot Function Index scores declined favorably from baseline (p < .001) at all time points (-32%, -46%, -49%, and -32%). The percentages of patients meeting satisfaction criteria were 72%, 85%, 90%, and 83%. The mean pain score during treatment 1 was 3.4, and during treatment 2, 2.9. Attrition of only 1 patient owing to pain occurred, after treatment 1. No adverse events occurred. Intense therapeutic ultrasound for chronic plantar fasciitis is shown to be effective, safe, and well tolerated in this pivotal clinical trial.

Validity and reliability of measurements of aponeurosis dimensions from magnetic resonance images.

Muscle performance is closely related to the structure and function of tendons and aponeuroses, the sheet-like, intramuscular parts of tendons. The architecture of aponeuroses has been difficult to study with magnetic resonance imaging (MRI) because these thin, collagen-rich connective tissues have very short transverse relaxation (T2) times and therefore provide a weak signal with conventional MRI sequences. Here, we validated measurements of aponeurosis dimensions from two MRI sequences commonly used in muscle-tendon research (mDixon and T1-weighted images), and an ultrashort echo time (UTE) sequence designed for imaging tissues with short T2 times. MRI-based measurements of aponeurosis width, length, and area of 20 sheep leg muscles were compared to direct measurements made with three-dimensional (3D) quantitative microdissection. The errors in measurement of aponeurosis width relative to the mean width were 1.8% for UTE, 3.7% for T1, and 18.8% for mDixon. For aponeurosis length, the errors were 7.6% for UTE, 1.9% for T1, and 21.0% for mDixon. Measurements from T1 and UTE scans were unbiased, but mDixon scans systematically underestimated widths, lengths, and areas of the aponeuroses. Using the same methods, we then found high inter-rater reliability (intraclass correlation coefficients >0.92 for all measures) of measurements of the dimensions of the central aponeurosis of the human tibialis anterior muscle from T1-weighted scans. We conclude that valid and reliable measurements of aponeurosis dimensions can be obtained from UTE and from T1-weighted scans. When the goal is to study the macroscopic architecture of aponeuroses, UTE does not hold an advantage over T1-weighted imaging.

New Approach for B-Mode Ultrasound (US) Evaluation of the Plantar Aponeurosis (PA) Thickness in Healthy Subjects.

PURPOSE: To compare ultrasound (US) measurements in the sagittal and axial plane of the plantar aponeurosis (PA) in healthy subjects. MATERIALS AND METHODS: PA thickness was measured in 40 healthy subjects (mean age: 34 years) by two radiologists using US in sagittal, axial medial and axial lateral planes. Subjects were classified according to gender (female and male) and age (18 - 35 versus 50 - 75 years). All measurements were compared and the interobserver agreement was calculated. RESULTS: The PA was medially significantly thicker than laterally (mean ± std 3.1 ±â€Š0.7 mm versus 2.5 ±â€Š0.5 mm respectively, P< 0.001). A significant difference was found between males and females (3.3 ±â€Š0.7 mm versus 2.9 ±â€Š0.6 mm medially and 2.7 ±â€Š0.6 mm versus 2.3 ±â€Š0.4 mm laterally, p < 0.05) and between the older and younger age groups (3.8 ±â€Š0.6 mm versus 2.8 ±â€Š0.4 mm medially and 3.1 ±â€Š0.4 mm versus 2.3 ±â€Š0.4 mm laterally, p < 0.001). Good interobserver agreement was detected (0.74). CONCLUSION: Measurement of central and lateral fascicles of the plantar aponeurosis in both planes (sagittal and axial) is recommended in the daily routine. KEY POINTS: · US examination of the central and lateral fascicles of the PA was feasible.. · PA thickness measurements showed significant differences based on age and gender.. · There was good interobserver correlation between both examiners despite the major difference in experience.. · Scanning of two planes for the PA is recommended in the daily routine.. · PA thickness measurement by US is a fast and reliable method for junior radiologists.. CITATION FORMAT: · Abd Ellah MM, Kremser C, Strobl S et al. New Approach for B-Mode Ultrasound (US) Evaluation of the Plantar Aponeurosis (PA) Thickness in Healthy Subjects. Fortschr Röntgenstr 2019; 191: 333 - 339.

Ultrasonographic Evaluation of the Femoral Cartilage, Achilles Tendon, and Plantar Fascia in Young Women Wearing High-Heeled Shoes.

BACKGROUND: Specific attention on the musculoskeletal impact of wearing high-heeled shoes (HHS) has mainly focused on knee osteoarthritis and the literature is limited to biomechanical changes. The distal femoral cartilage has not been morphologically studied. Additionally, although heel elevation is coupled with a shear stress at the heel and overloaded calf muscles, Achilles tendon (AT) and plantar fascia (PF) thicknesses have not been assessed either. OBJECTIVE: To investigate whether the distal femoral cartilage, AT, and PF were different in women wearing HHS and flat-heeled shoes (FHS) and specifically, different in terms of AT/PF and distal femoral cartilage thicknesses. DESIGN: Cross-sectional observational study. SETTING: Tertiary care center. PARTICIPANTS: There were 34 women (mean age; 31.1 ± 6.4, body mass index [BMI]; 21.6 ± 2.4 kg/m2 ) in the HHS group and 54 women (mean age; 29.5 ± 7.2 years, BMI 22.5 ± 2.9 kg/m2 ) in the FHS group (P = .271, P = .102, respectively). Women wearing shoes with a heel height of >5 cm were enrolled in the HHS group, and those wearing shoes with a heel height of <1.4 cm were included in the FHS group. MAIN OUTCOME MEASUREMENTS: Distal femoral cartilage from the lateral condyle, intercondylar area and medial condyle (MFC), AT and PF thicknesses, and any abnormalities were evaluated bilaterally by ultrasound. RESULTS: Within-group comparisons yielded thicker right MFC (P = .022) and left AT (P = .028) only in the HHS group. Between-group comparisons yielded thicker left AT in the HHS group (P = .040). PF thicknesses were similar both within and between group comparisons (all P > .05). Right AT thickness was positively correlated with right (r = .469, P = .005) and left (r = .402, P = .018) PF thicknesses only within the HHS group. Only calcaneal irregularity/spur was found to be common in the HHS group (P = .038). CONCLUSIONS: We found thickening of the right MFC and left AT in those wearing HHS, whereas PF thickness was not significantly different between those wearing HHS and those wearing FHS. LEVEL OF EVIDENCE: III.

Antagonist muscle architecture and aponeurosis/tendon strain of biceps femoris long head during maximal isometric efforts.

INTRODUCTION: Examination of the mechanical behavior of the hamstrings when acting as antagonists provides information about loading of this muscle group and its role for joint stability during forceful quadriceps contractions. The aim of this study was to quantify biceps femoris long head fascicle length (FL), angle of pennation (PA) and distal tendon/aponeurosis strain during maximum voluntary contraction efforts of the knee extensors using real-time ultrasound. METHODS: Fourteen participants performed passive joint movements and maximum voluntary knee extension and flexion efforts of the knee flexors at 0°, 45° and 90° of knee flexion. An ultrasound probe was used to visualize FL, PA and tendon/aponeurosis strain from the distal part of the muscle. RESULTS: Two-way analysis of variance designs indicated that: (a) antagonist BFlh tendon/aponeurosis strain increased significantly up to 2.77 ± 1.25% relative to rest (p < 0.05). The FL increased non-significantly (2.86 ± 6.81%) while the PA was unaltered during isometric MVC efforts of the knee extensors (p > 0.05) (b) FL, PA and tendon/aponeurosis strain of the BFlh when acting as antagonist were not significantly affected by knee joint angular position (p > 0.05). CONCLUSIONS: Antagonist hamstring function takes the form of a lengthened tendon/aponeurosis, no fascicle shortening and submaximal neural activation. Future research could examine whether exercise interventions that aim to alter tendon/aponeurosis mechanical properties of the hamstrings when acting as antagonists are beneficial for injury prevention and rehabilitation.

Muscle-tendon length and force affect human tibialis anterior central aponeurosis stiffness in vivo.

The factors that drive variable aponeurosis behaviors in active versus passive muscle may alter the longitudinal stiffness of the aponeurosis during contraction, which may change the fascicle strains for a given muscle force. However, it remains unknown whether these factors can drive variable aponeurosis behaviors across different muscle-tendon unit (MTU) lengths and influence the subsequent fascicle strains during contraction. Here, we used ultrasound and elastography techniques to examine in vivo muscle fascicle behavior and central aponeurosis deformations of human tibialis anterior (TA) during force-matched voluntary isometric dorsiflexion contractions at three MTU lengths. We found that increases in TA MTU length increased both the length and apparent longitudinal stiffness of the central aponeurosis at low and moderate muscle forces (P < 0.01). We also found that increased aponeurosis stiffness was directly related to reduced magnitudes of TA muscle fascicle shortening for the same change in force (P < 0.01). The increase in slope and shift to longer overall lengths of the active aponeurosis force-length relationship as MTU length increased was likely due to a combination of parallel lengthening of aponeurosis and greater transverse aponeurosis strains. This study provides in vivo evidence that human aponeurosis stiffness is increased from low to moderate forces and that the fascicle strains for a given muscle force are MTU length dependent. Further testing is warranted to determine whether MTU length-dependent stiffness is a fundamental property of the aponeurosis in pennate muscles and evaluate whether this property can enhance muscle performance.

Redefining the Rectus Sheath: Implications for Abdominal Wall Repair.

BACKGROUND: The abdominal wall is frequently manipulated in a variety of reconstructive procedures, and its anatomy is well described. The authors' clinical observations, however, contradict the standard depiction of the components of the abdominal wall at various levels-particularly regarding the course of the transversus abdominis muscle. Therefore, the authors sought to characterize the components of the rectus sheath at various surgical landmarks to define anatomic points important to abdominal wall repair. METHODS: The authors analyzed the abdominal computed tomographic studies of 100 healthy, young (age, 18 to 35 years; body mass index, 20 to 40 kg/m) patients with suspected renal calculi. Coordinates of key landmarks were recorded at vertebral levels T12 to L5 using a specially designed computer program that scaled all values and calculated distances between various points. RESULTS: All subjects had significant presence of the transversus abdominis within the rectus sheath (the overlap between the abdominis rectus and transversus abdominis muscles) at the costal margin plane (T12-L1, 4.2 cm). Ninety-nine percent had transversus abdominis presence within the rectus sheath at L1-L2 (3.2 cm), 86 percent at the level of the twelfth rib (L2-L3, 1.4 cm), 36 percent at the umbilicus (L3-L4), and 2 percent slightly above the posterosuperior iliac spine (L5-S1). CONCLUSIONS: These findings contradict classic teachings of abdominal wall structure and highlight the need for a cautious revisiting of the various permutations of component separation, particularly posterior component release. Furthermore, these anatomical landmarks may help predict the development or recurrence of ventral hernias, thus guiding patient selection and informing surgical technique.

A two-year follow-up of surgical and non-surgical treatments in patients with masticatory muscle tendon-aponeurosis hyperplasia.

This study re-examined the usefulness of surgery for the management of masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) through a comparison of the outcomes between patients who underwent surgery and those who did not. The duration of follow-up was 2 years. Twenty-eight patients who attended the study hospital and were given a diagnosis of MMTAH were included. Nineteen patients underwent surgery (surgical group) and nine patients were instructed to open their mouths wide once a day and did not undergo surgery (non-surgical group). Maximum mouth opening, impairment of daily activities, satisfaction, and the status of mouth opening training were evaluated after surgery. The mean increase in mouth opening after 2 years was 20.2mm in the surgical group and 2.4mm in the non-surgical group. Adequate mouth opening training led to satisfactory results 2 years postoperative, and sustained mouth opening training for 6 months after surgery was a key factor for obtaining good outcomes. The general condition and personality of individual patients should be evaluated carefully before surgery to estimate whether or not they can endure the pain associated with postoperative mouth opening training. The results of this study suggest that the surgical procedure is useful for the management of MMTAH.

[Palmar dislocation of the proximal interphalangeal joint and traumatic boutonnière deformity]. / Palmare Luxation im proximalen Interphalangealgelenk und traumatische Knopflochdeformität.

Injury to the central slip of the extensor tendon may occur with open and also with closed injuries, such as volar dislocation of the proximal interphalangeal (PIP) joint. For adequate treatment, it is necessary to identify all injured structures. Without appropriate primary management, the patient is likely to develop a subacute to chronic posttraumatic boutonnière deformity. A fixed boutonnière deformity requires recovery of joint mobility. Once joint mobility is achieved, secondary surgical reconstruction of the central slip can be performed with a tendon transfer or a tendon transplant.