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Dr Hijmans and Dr Dequeker presented an interesting argument for camptodactyly in the paintings of Dirk Bouts (November 2004 JRSM1). However, in their desire to distinguish these paintings from others of the period that show similar finger deformities, they misstate the nature of camptodactyly. Green's Operative Hand Surgery and the International Federation of Societies for Surgery of the Hand define camptodactyly as a congenital flexion deformity of the proximal interphalangeal joint of the fifth finger.2 Specifically, hyperextension of the distal interphalangeal joint is not necessary for the diagnosis; indeed, if this is present to a significant degree, the clinician should consider the possibility of a boutonnière deformity rather than camptodactyly. Also, extension of the metacarpophalangeal joint, while often present, is not a requirement for the diagnosis of camptodactyly.
While the exact cause of the deformity is not entirely known, it appears to be related to muscular abnormalities, particularly in the lumbrical or intrinsic muscles. It is present in both hands in two thirds of cases (in some, but not all, of the paintings by Bouts it is bilateral).
Shortly after reading the article by Hijmans and Dequeker I noted camptodactyly on one of the Christmas cards I was writing (Figure 1). This work, from the collection of the Metropolitan Museum of Art in New York, was painted by Gerard David (c. 1455–1523). Interestingly, this artist was independently mentioned by Dr Horton Johnson in his letter to the editor (February 2005 JRSM3) as one of several other examples of camptodactyly in art, although the painting he used was different.
In view of the number of artists and paintings that show evidence of camptodactyly (as defined by hand surgery authorities), it seems more likely that Bouts and his son were employing an artistic convention than that they were illustrating a hand deformity specific to their model.