Famous personalities and their osteoarticular disorders - the
classic X-ray point of view
Poster No.:
C-0940
Congress:
ECR 2013
Type:
Educational Exhibit
Authors:
A. M. Calin; Cluj - Napoca/RO
Keywords:
Genetic defects, Arthritides, Education, Plain radiographic studies,
Musculoskeletal joint, Musculoskeletal bone
DOI:
10.1594/ecr2013/C-0940
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Learning objectives
•
•
•
•
Review of the most important clinical and radiological aspects related to a
series of rheumatic and bone disorders
Underline the role of plain radiography in diagnosis work- up
Present a series of famous personalities who suffered from the presented
pathology
Reveal the way life and work of illustrious personalities was affected by their
medical condition
Background
Osteoarticular and rheumatic disease are still a ponderous chapter of the pathology a
radiologist has to deal with.
Some conditions, such as rheumatic arthritis, psoriatic arthritis, gout, pycnodysostosis,
osteogenesis imperfecta have affected emperors, kings, politicians, artits, writers and
have marked their lives and work.
Plain radiographs are still extremely valuable to help differentiate the forms of arthritis
and helpful in the diagnosis of bone disorders, the measuring of progression or in taking
a therapeutic decision, although more modern techniques have taken the lead role
nowadays.
Images for this section:
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Fig. 4: Alignment abnormalities of the 2nd, 3rd and 4th metacarpophalangeal (MCP)
joints, involving both hands.
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Imaging findings OR Procedure details
•
•
•
•
Peter Paul Rubens, a famous Flemish Baroque painter, a proponent
of an extravagant style that emphasized movement, colour, and
sensuality, well known for his Counter - Reformation altarpieces,
portraits, landscapes, and history paintings of mythological and
allegorical subjects.
Raoul Dufy, a French Fauvist painter, who developed a colorful,
decorative style that became fashionable for designs of ceramics and
textiles, as well as decorative schemes for public buildings. He is
noted for scenes of open-air social events. He was also a draftsman,
printmaker, book illustrator, a theatrical set-dresser, a designer of
furniture, and a planner of public spaces.
Christiaan Neethling Barnard, a South African cardiac surgeon
who performed the world's first successful human-to-human heart
transplant.
Édith Piaf, French singer who became widely regarded as France's
national popular singer, as well as being one of France's greatest
international stars. Her singing reflected her life, with her specialty
being ballads.
What did they all have in common?They all suffered from...
RHEUMATOID ARTHRITIS
Rheumatoid arthritis (RA) is a chronic systemic disease of unknown origin that
predominantly involves synovial tissue. Early diagnosis and proper treatment help modify
the course of the disease and reduce the degree of severe late sequelae. Radiology is
very important in the diagnosis and management of RA.
Currently, radiographs, computed tomography (CT), scintigraphy, magnetic resonance
imaging (MRI), and ultrasound are the imaging tools available . Radiographs continue to
be the mainstay; however, advanced imaging techniques improve early diagnosis and
more accurately monitor therapy and disease progression.
For diagnostic purposes, symptomatic joints and joints typically involved in RA (wrist and
hand joints) should be examined. In the follow-up, wrist and hand joints are preferred
sites to assess the treatment efficacy.
Radiology depicts joint derangement and mirrors the pathophysiological process of RA.
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Radiography
Radiography is the initial imaging modality for the
workup and monitoring of patients with RA and radiographic findings may confirm the
clinical suspicion of RA or may suggest other diagnostic possibilities.
The benefits of radiography include low cost, high availability,
possibility of standardization and centralized reading and reproductibility.
Because of its finely detailed resolution and depiction of bony structures, radiography is
very useful at detecting erosions. Bone demineralization (osteopenia/osteoporosis) could
be observed on radiography but not on ultrasound or MRI.
Radiographs are often capable to provide a general image of regional arthritis damage.
Disadvantages of radiography include limited visualization of bones and soft tissue, the
relative insensitivity to early damage and limited view of soft tissue abnormalities.
Conventional radiography may help differentiate RA from
other joint pathologic entities such as osteoarthritis (OA), psoriatic
arthritis, and tumoral processes and it may help in discovering a secondary process
affecting the joint of patients with known RA, such as osteomyelitis, septic arthritis,
pathologic or stress fractures, and amyloidosis.
Early Radiographic Findings:
- Nonspecific periarticular soft tissue swelling
- Periarticular osteopenia
Classic Radiographic Findings:
- Marginal erosions in the " bare areas "
- Cartilage loss
- Hypertrophic bone formation, osteosclerosis
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or repair of erosions
Late Radiographic Findings
- Subluxations
- Pressure erosions
- Loss and obliteration of the cartilage space
- Ankylosis
- Secondary osteoarthritis (OA)
Distribution of Articular Involvement
Radiological findings in RA are generally symmetrical and
polyarticular. RA targets synovial joints and has a predilection for
symmetric involvement of the distal extremities, hands, wrists,
and feet, but the elbows, knees, shoulders, and hips are often
affected.
Involvement of the cervical spine occurs in up to 70% of all patients with RA, therefore
patients are at an increased risk of multidirectional subluxation at the C1-2 level!
Radiographic Appearance in Specific Joints
Hands
The best described alterations in patients with RA are the ones of the hands.
Soft tissue swelling and periarticular osteoporosis occur early in the disease and affect
mostly the index and middle finger metacarpophalangeal (MCP) joints.
Marginal erosions and concentric loss of cartilage develop during the disease progression
and lead to malalignment and ankylosis.
Soft Tissues
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The character and distribution of soft tissue swelling in the hands are important in
identifying early RA.
Localization of soft tissue swelling to the proximal interphalangeal (PIP) joints and MCP
joints is suggestive of RA even in the absence of bone abnormalities.
Fusiform swelling of the PIP joints is characteristic for RA.
Fig. 1: Early findings in rheumatoid arthritis: fusiform soft tissue swelling involving all
fingers, osteoporosis localized at the MCP joints of both hands and small erosions
(proximal phalanges).
References: - Cluj - Napoca/RO
Erosions
The earliest bone changes take place at the bare areas of the radial aspects of the MCP .
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Magnification radiographs depict the marginal erosions as localized cortical thinning and
a dot-and-dash pattern of cortical disruption. In time, marginal erosions show loss of
cortex with or without preservation of underlying trabeculation.
In addition, compressive (pressure) and superficial surface resorption may occur in the
hands, due to collapse of osteoporotic bone as muscular forces pull the articular surfaces
together, typically at the MCP joints.
Fig. 2: Marginal erosions affecting the metacarpophalangeal joints (MCP) and
proximal interphalangeal (PIP) joints of both hands.
References: - Cluj - Napoca/RO
Ankylosis
As destruction of cartilage and bone advances, the joint space
may be destroyed completely, leading to a fibroosseous fusion
of joints after complete cartilage loss. This represents the chronic,
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end-stage sequela of RA.
Ankylosis may occur at the MCP and PIP joints, but this sequela is more frequent in the
carpal and tarsal bones.
Fig. 3: Fibroosseous fusion of joints after complete cartilage loss, especially visible in
the PIP joints of the right hand.
References: - Cluj - Napoca/RO
Malalignment
The direct effect of the disease on the articulations, tendons, and ligaments causes
alignment abnormalities of the hand, which are common and classic in RA. Prototypal
alignment abnormalities include swan-neck, boutonnie`re and windswept deformities,
and flexion/hyperextension-subluxation/dislocations at the thumb.
Swan-neck deformity is the result of hyperextension at the PIP joint
and flexion at the DIP joint.
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Boutonnie`re deformity is a combination of flexion at the proximal
interphalangeal and extension at the DIP joints.
Windswept affects the MCP and PIP joint deformities and patients with windswept
deformity have symmetric ulnar subluxations and dislocations of the MCP and PIP joints.
In some cases, ulnar deviation and palmar subluxations may appear.
Fig. 4: Alignment abnormalities of the 2nd, 3rd and 4th metacarpophalangeal (MCP)
joints, involving both hands.
References: - Cluj - Napoca/RO
New Bone Formation
Increased amounts of endosteal bone may form in the distal phalanges, creating the
condition called terminal phalangeal sclerosis or acral sclerosis.
In patients treated with methotrexate or with an anti-tumor necrosis factor antibody, repair
of erosions may occur and bone density may increase.
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Wrists
Alterations in the wrists include soft tissue swelling, erosions, joint space narrowing,
alignment abnormalities and ankylosis, which tend to assemble in particular locations
in the joints and follow a specific distribution. Abnormalities in the wrist are usually
accompanied by involvement in the fingers, either concomitantly or following carpal
dominant rheumatoid disease.
Soft Tissues
Soft tissue swelling is depicted on radiographs by obliteration
of the fat lines and increased density of the soft tissues and may be present at any of
the compartments of the wrist.
RA affects intercarpal, carpometacarpal, and radiocarpal joints;
overlying tendons; and/or the ligamentous structures.
A characteristic early finding in RA is the tissue swelling at the medial aspect of the ulnar
styloid.
Rheumatoid involvement of the tendons coursing through the
carpal tunnel may lead to carpal tunnel syndrome.
Erosions
Erosions commonly affect the intercarpal and radiocarpal articulations symmetrically
and, as with other joints, bare areas and bony locations adjacent to synovitis are more
exposed.
A common site for early erosion in RA is the ulnar styloid, together with erosions of the
triquetrum and pisiform bones, although the disease can affect any carpal bone.
Ankylosis
Pancompartmental changes in the wrist with obliteration of the joint spaces, large
osseous erosions, and bony ankylosis will occur due to disease progression.
This pancompartmental distribution is characteristic for RA and is extremely unlikely to
be the result of other disease processes that usually involve only selected compartments.
Malalignment
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Wrist malalignment and deformity generally fit several welldescribed
patterns of radiocarpal, intercarpal, and radioulnar/distal ulnar malalignment but because
of the intricate relationships and
number of ligaments, tendons, and bones at the wrist, the classification of wrist
malalignment and deformity should serve primarily as a guide, as there is overlap among
the different types.
Radiocarpal malalignment consists in ulnar and palmar deviation of the proximal carpal
row as the carpus slides off the inclined articular surface of the distal radius.
Intercarpal malalignment may develop in dorsal or volar directions. Dorsal intercalated
segment instability (DISI) results in an increased scapholunate angle (normal, 45
degrees) on lateral radiographs while the decrease of the scapholunate angle results in
volar intercalated segment instability (VISI).
Inferior radioulnar and distal ulnar malalignment enclose dorsal subluxation of the distal
ulna and diastasis of the inferior radioulnar compartment.
Scapholunate advanced collapse (SLAC) may also occur in patients with RA.
But maybe the most notable personality who has suffered from RA is Pierre
Auguste Renoir, a French artist, one of the leading painters of the Impressionist
style.
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Fig. 5: Renoir painting at Cagnes-sur-Mer, with the brush fixed to his hand.
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References: Boonen A., van de Rest J., Dequeker J.,van der Linden S. How Renoir
coped with rheumatoid arthritis. BMJ 1997;315:1704. License number: 3077060739384
He was diagnosed around the age of 50. His arthritis proved to be rheumatoid at the 13th
European meeting of Rheumatology in 1955, based on revealed facts by the painter`s
grandson, Paul Renoir.
In his case, the disease firstly involved the small joints of the hands and feet, leading to
deformities and ankylosis, and later extended to the shoulders and his right arm. He was
unable to pick up the brush or hold the pallette, walked difficultly and he finally ended
up in a wheelchair.
Despite his disease, he continued painting.
His family helped him wedge the brush around his fingers and he even became
ambidexter so he could continue his work.
Instead of being influenced by his disease, he painted more joyfully than in the past,
sustaining that " There are enough unpleasant things in the world. Why shouldn't
art be pretty?".
In his last years, he also turned his interest into sculpture. He used the hands of a young
artist, who modellated what Renoir imagined.
Renoir had a strong wish to acquire nature and beauty, so he painted till the end of his life.
In the day the artist died, at 78, he had painted for several hours, declaring the following:
"I think I am beginning to know something about painting".
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Fig. 6: "Bal du moulin de la Galette" - Pierre Auguste Renoir 1876
References: www.wikipedia.org
•
•
Vladimir Nabokov, Russian American novelist, who's most famous
novel " Lolita " became known wolrdwide
Joseph Vissarionovich Stalin, Premier of the Soviet Union and one of
the most notorious Soviet leaders....
....both experienced...
PSORIATIC ARTHRITIS
Patients with psoriasis who have peripheral arthritis are also at
increased risk to develop inflammatory disease of the spine and sacroiliac joints.
Classic findings consist in unilateral or asymmetric sacroiliitis, asymmetric
syndesmophytes, nonmarginal syndesmophytes that do not develop along consecutive
vertebrae, paravertebral ossification that may become large and bulky, and more frequent
involvement of the cervical spine.
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Psoriatic arthritis affects the hands almost twice as frequently as
the feet.
Osteoporosis appears in psoriatic arthritis only when the disease is advanced, and the
presence of polyarthritis is often associated with involvement of the distal interphalangeal
joints ( DIP ).
Another common pattern of disease that may also affect the wrist is the asymmetric
oligoarticular involvement.
A severe, deforming pattern of disease may also occur with bony ankylosis and
malalignment that may ultimately progress to an arthritis mutilans, leading to the so called
"opera glass" (main en lorgnette) aspect.
In contrast to RA, dactylitis - the "sausage digit" appearance is a classic finding in psoriatic
arthritis.
Bony proliferation occurs bordering to the erosions of psoriatic arthritis.
When psoriatic arhtritis reaches the feet, the interphalangeal and metatarsophalangeal
joints are most frequently affected, particularly the great toe, which will often contain an
" ivory phalanx".
Inflammatory enthesopathy, comparable to that occurring in reactive arthritis and tipically
affecting the hindfoot and ankle, is another characteristic feature of psoriatic arthritis.
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Fig. 7: "Sausage-digit" appearance, a classic finding in psoriatic arthritis, concerning
the 3rd and 4th finger of the right hand. Erosive alterations are also noticeable in the
right DIP joints, particularly in the 3rd finger.
References: - Cluj - Napoca/RO
•
•
•
•
•
Karl Marx, German philosopher, economist, sociologist, historian,
journalist and revolutionary socialist
Benjamin Franklin, politician and scientist, famous for his discoveries
and theories regarding electricity
Henry the VIIIth, king of England
Isaac Newton, physicist, mathematician, astronomer, alchimist,
theologian, considered to be the most influential scientist of all times
Thomas Sydenham, English physician, also known as "English
Hippocrates"
...all affected by the notable " Disease of the kings"...
GOUT
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Gout has been known since antiquity, affecting mostly wealthy adult men, but its cause
(an extracellular urate supersaturation that results in the deposition of monosodium urate
crystals [MSU] in the tissues) was not identified until the last half of the 20th century.
Crystal deposition incites a complex inflammatory response that
damages the tissue.
The disease may take the form of intermittent acute attacks
of a red, swollen, painful joint or chronic arthropathy.
Fig. 8: "Gout", a 1799 caricature by James Gillray
References: www.wikipedia.org
Diagnosis of gout derives from the presence of hyperuricemia, clinical history,
radiographic findings, MSU crystal identification, or rapid symptom resolution after
colchicine therapy.
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Radiographs
Radiographic findings of gout are characteristic.
Intraarticular or paraarticular erosions have a round to oval shape, well-defined sclerotic
borders, giving them a punched-out appearance, while the bone adjacent to the erosions
may extend outward to produce an "overhanging margin."
The joint spaces are often well maintained until late in the disease.
The tophi cause a nodular appearance and are common in patients
who have had a long history of gout and poor response to treatment.
The typical radiographic findings appear only after many years of disease progress and
the early diagnosis is mostly clinical.
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Fig. 9: Paraarticular erosions with punched-out appearance and overhanging margin
aspect, typically affecting the first metatarsophalangeal (MTP) joint of the left foot of a
male patient. The joint spaces are well preserved.
References: - Cluj - Napoca/RO
Gout is asymmetric and polyarticular and commonly affects the feet. The initial sign is
an acute inflammation of the first metatarsophalangeal (MTP) joint, but also other MTP
joints, the midfoot and the hindfoot may be involved.
The disease often alters the distal interphalangeal, proximal interphalangeal, and
intercarpal joints of the hand.
Less commonly affected joints are the knee, the sacroiliac joint and the spine.
The focal collections of crystals (tophi) arise in the synovium, ligaments, tendons, and
bursae. A predilection for the patella and no calcifications are observed when the tophi
are intraosseous. They can mimic a malignancy, because of their aggresive appearance.
Extraarticular tophi tend to develop in the olecranon bursa, the prepatellar bursa, and the
dorsum of the foot.
Tophi sometimes can cause erosion of bones and soft tissues, leading to fractures and
tendon ruptures.
Gout sometimes coexists with other articular disorders and when radiographic findings
of multiple entities occur together, diagnosis may be difficult.
An accurate and vivid description of a gout attack was written in 1683 by Dr. Thomas
Sydenham, who suffered himself of gout:
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Fig. 10: Dr. Thomas Sydenham
References: www.wikipedia.org
"The victim goes to bed and sleeps in good health. About 2 o'clock in the morning,
he is awakened by a severe pain in the great toe; more rarely in the heel, ankle or
instep. This pain is like that of a dislocation, and yet the parts feel as if cold water
were poured over them. Then follows chills and shiver and a little fever. The pain
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which at first moderate becomes more intense. With its intensity the chills and
shivers increase. After a time this comes to a full height, accommodating itself to
the bones and ligaments of the tarsus and metatarsus. Now it is a violent stretching
and tearing of the ligaments- now it is a gnawing pain and now a pressure and
tightening. So exquisite and lively meanwhile is the feeling of the part affected, that
it cannot bear the weight of bedclothes nor the jar of a person walking in the room."
•
Michael J. Anderson , American actor, known for his roles as the Man
From Another Place in David Lynch's television series Twin Peaks, the
epilogue and prologue film of the series, TwinPeaks: FireWalk with Me,
and Samson Leonhart on the HBO series Carnivale. While many people
assume Anderson is a dwarf, he actually has the genetic disorder
Osteogenesis imperfecta. This disease lead to frequent breaks in his
long bones and improper healing, leaving him with a shortened stature
of 1.09m.
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Fig. 11: Michael J. Anderson - October 31, 1953 (age 59)
References: www.wikipedia.org
OSTEOGENESIS IMPERFECTA
Osteogenesis imperfecta represents a spectrum of genetic disorders that affect the
bony structures, their adjacent ligaments, the overlying skin, the sclera and the dentin,
representing the most common genetic cause of osteoporosis.
In most cases, the cause is a reduction in the production or the synthesis of normal type
I collagen as a result of a mutation in the type I collagen genes (COL1A1 and COL1A2 ),
found on the 7th chromosome.
Osteogenesis imperfecta has been also known as osteopsathyrosis, Vrolik's disease,
fragilitas ossium, mollities ossium, Lobstein's disease, and van der Hoeve syndrome.
The clinical diagnosis of osteogenesis imperfecta is based
primarily on the following manifestations: osteoporosis, abnormal fragility of the skeleton,
blue sclera, dentinogenesis imperfecta (grey teeth), hyperlaxity of the ligaments and skin,
hearing loss, and the
presence of Wormian bones on skull radiographs.
Type I:
- autosomal dominant disease
- blue sclera, increased tendency to sustain fractures, and ligamentous laxity
- the most common and mildest form of this disease ( 60 % )
- few fractures in childhood and puberty
- normal height or within 2 standard deviations
- early hearing loss
- IA without dentinogenesis imprefecta
- IB with dentinogenesis imperfecta
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Type II:
- most severe form
- dwarfism and severe bone deformities
- death in neonatal period
Type III:
- 20 % of the patients
- intrauterine fractures and growth retardation
- skeletal deformities at birth
- the most dramatic form of dwarfism
- large, asymmetric head and triangle-shaped face
- dentinogenesis imperfecta associated
- death due to respiratory illness or basilar invagination
Type IV:
- autosomal dominant disease
- similar to type I, but with a greyish sclera, shorter stature and denting imperfection
Type V:
- white sclera
- moderate to severe bone fragility
- osteopenia
- hypertrophic callus formation
- no dentinogenesis imperfecta involved
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Type VI:
- moderate to severe form with accumulation of osteoid due to mineralization deffect
- underlying genetic defect and inheritance remain unknown
Type VII:
- recently described in a community of Native Americans in Quebec
- besides the common features, rhizomelia and an autosomal recessive inheritance
Characteristic findings on radiography:
- diffuse decrease in bone density, both in axial and appendicular skeleton - thin, gracile
bones
- fractures of the extremities, especially of the lower limb
- bone deformities - bowing of long bones, dislocations, coxa vara, genu valgum,
scoliosis, limb length discrepancies, micromelia
- cystic bone appearance
- hypotrophic callus formation, with pseudotumoral aspect
- "popcorn calcifications" in children with severe consequences
- premature degeneration of the joints
- skull: enlarged frontal and mastoid sinuses, increased number of Wormian bones (more
than 10) with a mosaic pattern, platybasia, basilar invagination
- spine: biconcave vertebrae, kyphoscoliosis
- pelvis: narrowed and with a triradiate shape, protrusion of acetabula
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Fig. 12: Osteogenesis imperfecta: severe osteoporosis, long bone deformities and
healed fractures in the case of a young boy.
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References: - Cluj - Napoca/RO
Page 29 of 56
Fig. 13: Thin, gracile bones, with bowing of the diaphyseal part and coxa vara in the
case of a young boy.
References: - Cluj - Napoca/RO
Most of the cases with severe osteogenesis imperfecta cand be detected during prenatal
ultrasound examination. This examination will not differentiate between the forms of the
disease, but will provide a fetal prognosis.
•
Henri de Toulouse-Lautrec, French painter, printmaker, draughtsman
and illustrator whose immersion in the colourful and theatrical life
of Paris in the late 1800s yielded a collection of exciting, elegant and
provocative images of the modern and sometimes decadent life of
those times. Toulouse-Lautrec, along with Cezanne, Van Gogh and
Gaugin, are among the greatest painters of the Post - Impressionist
period.
Fig. 14: Mr. Toulouse paints Mr. Lautrec, 1891
References: www.wikipedia.org
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PYCNODYSOSTOSIS is also known as Toulouse - Lautrec syndrome, after the
famous painter who suffered from it.
Pycnodysostosis represents a rare autosomal recessive disorder indicated by
generalized osteosclerosis and short stature.
Clinical features:
- short, but proportionate stature
- multiple fractures
- craniofacial malformations
- narrow chest, pectus excavatum
- kyphoscoliosis
- hypermobile joints
- broad extremities, short fingers
Radiographic findings:
- generalized increase in bone density
- multiple fractures of varying ages
- sparing of the medullary cavity with normal haematopoietic function
- hypoplastic facial bones
- persistent open fontanelle and cranial sutures
- micrognathia
- dental abnormalities
- kyphoscoliosis
- increased lumbar lordosis
- dense vertebral bodies
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- spool-shaped vertebral bodies
- widening of the distal femur
- coxa valga
- acro-osteolysis
Toulouse Lautrec mainly surprised distinctive images of the Parisian lifestyle "I paint
things as they are. I don`t comment."
For many years, medical historians have tried to figure out what caused the artist`s
physical and psychological problems.
His parents, the Count Alphonse and the Countess Adèle de Toulouse-Lautrec, were
cousins, as it was common in most aristocratic French families. Their consanguinity most
probably contributed to the congenital condition of the diminutive painter. Also other
cousins and relatives of the painter suffered from dwarfism and skeletal disorders.
He was short and sickly during his childhood. He fractured both of his legs in his teenage
years; his feet did never heal properly, nore did they grew over that point so he was
forced to use a cane for the rest of his life. Spending most of his time indoors, under the
influence of an artistic family, his love for the arts and talent emerged.
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Fig. 15: "An Examination at the Faculty of Medicine", Paris 1901 - Henri de Toulouse
Lautrec
References: www.wikipedia.org
As a young adult, he reached the height of 1.52m, with a normal torso and normal upper
limbs, but with the legs of a child. He had a large forehead and nose, a receding chin,
toothaches and always wore a black hat, which added a few inches to his height. There
were also rumours of his abnormal genitalia, despite his popularity among women.
At the age of 18, he moved to Paris, opened a studio in Montmartre and started taking
part of the vibrant night life of Paris. He became famous after creating several poster ads
for the local cabartes, but he also started drinking heavily (he always carried a supply of
absinthe in his hollow walking stick). He was considered to be a local eccentric personality
and a fixture at Moulin Rouge and other cabarets.
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Fig. 16: Théophile-Alexandre Steinlen - "Tournée du Chat Noir de Rodolphe Salis",
representation of one of the painter`s favourite cabarets in Paris
References: www.wikipedia.org
The artist died young because of a stroke caused by severe alcholism and syphilis,
leaving behind a great debate upon his condition.
Toulouse Lautrec absorbed the local swirl into thousands of paintings, litographs,
illustrations and posters, thus receiving worlwide recognition.
Images for this section:
Fig. 1: Early findings in rheumatoid arthritis: fusiform soft tissue swelling involving all
fingers, osteoporosis localized at the MCP joints of both hands and small erosions
(proximal phalanges).
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Fig. 2: Marginal erosions affecting the metacarpophalangeal joints (MCP) and proximal
interphalangeal (PIP) joints of both hands.
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Fig. 3: Fibroosseous fusion of joints after complete cartilage loss, especially visible in
the PIP joints of the right hand.
Page 37 of 56
Fig. 4: Alignment abnormalities of the 2nd, 3rd and 4th metacarpophalangeal (MCP)
joints, involving both hands.
Page 38 of 56
Fig. 5: Renoir painting at Cagnes-sur-Mer, with the brush fixed to his hand.
Page 39 of 56
Fig. 6: "Bal du moulin de la Galette" - Pierre Auguste Renoir 1876
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Fig. 7: "Sausage-digit" appearance, a classic finding in psoriatic arthritis, concerning the
3rd and 4th finger of the right hand. Erosive alterations are also noticeable in the right
DIP joints, particularly in the 3rd finger.
Page 41 of 56
Fig. 8: "Gout", a 1799 caricature by James Gillray
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Fig. 9: Paraarticular erosions with punched-out appearance and overhanging margin
aspect, typically affecting the first metatarsophalangeal (MTP) joint of the left foot of a
male patient. The joint spaces are well preserved.
Fig. 10: Dr. Thomas Sydenham
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Fig. 11: Michael J. Anderson - October 31, 1953 (age 59)
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Fig. 12: Osteogenesis imperfecta: severe osteoporosis, long bone deformities and
healed fractures in the case of a young boy.
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Fig. 13: Thin, gracile bones, with bowing of the diaphyseal part and coxa vara in the case
of a young boy.
Fig. 14: Mr. Toulouse paints Mr. Lautrec, 1891
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Fig. 15: "An Examination at the Faculty of Medicine", Paris 1901 - Henri de Toulouse
Lautrec
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Fig. 16: Théophile-Alexandre Steinlen - "Tournée du Chat Noir de Rodolphe Salis",
representation of one of the painter`s favourite cabarets in Paris
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Fig. 17: Photo of Henri Tolouse Lautrec
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Conclusion
Although it remains in the shadow of more modern tehchniques, the plain radiography
represents the "basic knowledge" for a radiologist.
The best way to understand the impact of a medical condition on a patient is to analyse
the way influential personalities handled and described their disease.
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Personal Information
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