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Clinical exam · Musculoskeletal system

Hand deformities: Heberden, Bouchard, swan neck, boutonnière !

  • Sign

The shape of the fingers tells which arthritis a person has: hard nodes in osteoarthritis and bent or drifting fingers in rheumatoid arthritis.

Updated 2026-11-01

See it in 3D: Volar plates (fingers) · Volar plates (knuckles) · Knuckle collateral ligaments · Finger joint capsules · Middle phalanx, middle finger · 3rd metacarpal

What it is

Many joint diseases leave typical deformities in the hand. Heberden and Bouchard nodes are bony growths of osteoarthritis; swan neck, boutonnière and ulnar deviation of the fingers are typical of long-standing rheumatoid arthritis. Recognising them on inspection points to the diagnosis before any test.

The anatomy it tests

  • Each finger's extensor mechanism has a central slip that inserts on the middle phalanx and two lateral bands that reach the distal phalanx.
  • Boutonnière: the central slip tears or stretches, the PIP flexes and pokes between the lateral bands, which slip palmward and hyperextend the DIP.
  • Swan neck: the PIP volar plate gives way and the lateral bands shift dorsally, hyperextending the PIP; the deep flexor flexes the DIP.
  • Ulnar deviation: MCP synovitis stretches the capsule and collateral ligaments, and the extensor tendons slide to the ulnar side.
  • Heberden and Bouchard nodes are osteophytes at the edges of joints with worn cartilage.

How to elicit it

  1. Patient seated, both hands exposed and resting on a pillow, first palms down and then palms up.
  2. Look closely at the DIP, PIP and metacarpophalangeal joints and the wrists, comparing both hands.
  3. Feel each node: hard and cool is bone (osteoarthritis); soft, warm and tender is synovitis (inflammatory arthritis).
  4. Look at each finger from the side to see the resting posture of the PIP and DIP joints.
  5. Ask for a fist and then full finger extension: see whether the deformity corrects or is fixed, and whether the fingers drift ulnarly.
  6. Finish with grip strength, muscle wasting, the nails (pitting) and the skin (plaques).

What a positive result means

  • Heberden and Bouchard nodes: hand osteoarthritis, more common in older women; usually painless between flares.
  • Swan neck, boutonnière, ulnar deviation and MCP subluxation: long-standing rheumatoid arthritis.
  • Swan neck also after an untreated mallet finger or from ligament laxity.
  • Boutonnière also after trauma that ruptures the central extensor slip over the PIP joint.
  • DIP involvement with nail pitting or skin plaques: psoriatic arthritis.
  • Deformities in lupus that the examiner can correct by hand (Jaccoud arthropathy) are reducible, unlike rheumatoid ones.

Usefulness and limits

  • Early rheumatoid arthritis has no deformities: what is seen is soft swelling of the MCP and PIP joints.
  • Hand radiographs separate osteophytes (osteoarthritis) from erosions (rheumatoid arthritis).

Test yourself

Think of the answer, then tap the question to see it.

At which joints do Heberden and Bouchard nodes appear?

Heberden at the distal interphalangeal joints and Bouchard at the proximal interphalangeal joints; both are signs of osteoarthritis.

How is the swan neck deformity described?

Hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint.

Which structure ruptures in the boutonnière deformity?

The central slip of the extensor mechanism over the proximal interphalangeal joint; the lateral bands slip toward the palm.

Which arthritis involves the distal interphalangeal joints and which spares them?

Osteoarthritis and psoriatic arthritis involve them; rheumatoid arthritis typically spares them.

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See it in 3D

The structures of Durgical's 3D anatomy where it is found.

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Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: Musculo-Skeletal Examination – Hand Exam – Practical Guide to Clinical Medicine (UC San Diego School of Medicine, 2026); Swan neck deformity (WikEM, 2026); Rheumatoid arthritis (WikEM, 2026).

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Representative model, for educational purposes only.