[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Musculoskeletal system](https://durgical.com/en/clinical-exam/#a-musculoskeletal) › Hand deformities: Heberden, Bouchard, swan neck, boutonnière [Clinical exam](https://durgical.com/en/clinical-exam/) · [Musculoskeletal system](https://durgical.com/en/clinical-exam/#a-musculoskeletal) # 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)](https://durgical.com/en/anatomy/volar-plates-of-the-interphalangeal-joints/) · [Volar plates (knuckles)](https://durgical.com/en/anatomy/volar-plates-of-the-mcp-joints/) · [Knuckle collateral ligaments](https://durgical.com/en/anatomy/collateral-ligaments-of-the-metacarpophalangeal-joints/) · [Finger joint capsules](https://durgical.com/en/anatomy/finger-joint-capsules/) · [Middle phalanx, middle finger](https://durgical.com/en/anatomy/middle-phalanx-of-the-middle-finger/) · [3rd metacarpal](https://durgical.com/en/anatomy/3rd-metacarpal/) ## Key points - Heberden: bony nodes at the distal interphalangeal (DIP) joints; Bouchard: at the proximal interphalangeal (PIP) joints; both from osteoarthritis. - Swan neck: PIP hyperextension and DIP flexion. - Boutonnière: PIP flexion and DIP hyperextension, from rupture of the central slip of the extensor. - Ulnar deviation of the fingers at the metacarpophalangeal joints: advanced rheumatoid arthritis. - Rheumatoid arthritis spares the DIP joints; psoriatic arthritis involves them. ## 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 - Patient seated, both hands exposed and resting on a pillow, first palms down and then palms up. - Look closely at the DIP, PIP and metacarpophalangeal joints and the wrists, comparing both hands. - Feel each node: hard and cool is bone (osteoarthritis); soft, warm and tender is synovitis (inflammatory arthritis). - Look at each finger from the side to see the resting posture of the PIP and DIP joints. - Ask for a fist and then full finger extension: see whether the deformity corrects or is fixed, and whether the fingers drift ulnarly. - 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). ## Memory aid Heberden at the tip, Bouchard at the bridge: osteoarthritis works from the nail toward the middle of the finger. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/hand-deformities-heberden-bouchard-swan-neck-boutonniere/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Volar plates (fingers)](https://durgical.com/en/anatomy/volar-plates-of-the-interphalangeal-joints/) - [Volar plates (knuckles)](https://durgical.com/en/anatomy/volar-plates-of-the-mcp-joints/) - [Knuckle collateral ligaments](https://durgical.com/en/anatomy/collateral-ligaments-of-the-metacarpophalangeal-joints/) - [Finger joint capsules](https://durgical.com/en/anatomy/finger-joint-capsules/) - [Middle phalanx, middle finger](https://durgical.com/en/anatomy/middle-phalanx-of-the-middle-finger/) - [3rd metacarpal](https://durgical.com/en/anatomy/3rd-metacarpal/) ## Related - [Joint examination: inspection, palpation and range of motion](https://durgical.com/en/clinical-exam/joint-examination-inspection-palpation-and-range-of-motion/) - [Phalen and Tinel signs](https://durgical.com/en/clinical-exam/phalen-and-tinel-signs/) - [Finkelstein test](https://durgical.com/en/clinical-exam/finkelstein-test/) ## Related conditions - [Rheumatoid arthritis of the hand and wrist](https://durgical.com/en/conditions/rheumatoid-arthritis-of-the-hand-and-wrist/) - [Rheumatoid arthritis](https://durgical.com/en/conditions/rheumatoid-arthritis/) - [Psoriatic arthritis](https://durgical.com/en/conditions/psoriatic-arthritis/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) 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](https://sites.ucsd.edu/clinicalmedguide/musculo-skeletal-examination-hand-exam/) (UC San Diego School of Medicine, 2026); [Swan neck deformity](https://wikem.org/wiki/Swan_neck_deformity) (WikEM, 2026); [Rheumatoid arthritis](https://wikem.org/wiki/Rheumatoid_arthritis) (WikEM, 2026). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/hand-deformities-heberden-bouchard-swan-neck-boutonniere/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/hand-deformities-heberden-bouchard-swan-neck-boutonniere/