Earliest Roentgenological Changes in Polyarthritis of the Rheumatoid Type: Rheumatoid Arthritis

Published Online:https://doi.org/10.1148/85.2.325

In spite of the many laboratory tests available, the clinical diagnosis of “rheumatoid arthritis” is often difficult in the initial stages, especially in the subacute cases. The diagnosis is even more difficult in the middle-aged and elderly, in whom other types of joint disorders, like degenerative arthrosis, may be complicated by rheumatoid arthritis.

Because more or less efficient therapy of rheumatoid arthritis is now available, the need of an early certain diagnosis is all the greater. The risk of undesirable effects of steroids and gold salts contraindicates their use in uncertain diagnoses. For the same reason, diagnosis “e juvantibus” is inadmissible.

X-ray examinations have so far been of no great value in the early diagnosis of this condition. What have usually been described (1–4) as early roentgen changes—narrowing of the joint space, “punchedout” areas of bone, and even the marginal defects of the metacarpal heads seen in the pronate position—without any doubt need months or even years to develop. In the past these examinations have therefore mostly provided help in the differentiation between certain characteristic types of polyarthritis and in stage-grouping these diseases (5).

In the X-Ray Department of Kommunehospitalet, Copenhagen, we have for more than fifteen years performed systematic and repeated examinations of patients with joint symptoms of short duration in an attempt to find roentgen changes indicating rheumatoid arthritis, which precede the just-mentioned, so-called “early” changes. By a special, but very simple, conventional technic we have succeeded in demonstrating such slight but still significant osseous changes. By these the diagnosis of rheumatoid arthritis may be made in many cases as early as—and in certain instances even before—it is possible by means of laboratory tests, etc.

Technic

X-ray examination of both the hands, together with the wrists, and of both forefeet have been routine. A relatively soft radiation (tube voltage 60–65 kv) and fine-grain : film have been employed without intensifying screens, as we aimed at a clear demonstration of the soft tissues. Apart from exposure in the frontal plane (dorsovolar projection) we have now for more than nine years systematically also examined both hands and wrists in a halfway supinate position, with the hands and fingers leaning against oblique wedges of plastic foam. Other exposures, as the profile and halfway pronate, have been abandoned as of no supplementary value (6).

In many cases the fine-focus enlargement technic of van der Plaats was also used for the same projections, but apart from a clearer demonstration of the slightest changes in some instances, nothing fundamental was gained thereby. Moreover, in certain patients the necessary longer time of exposure made avoidance of slight movements difficult. Study of the routine roentgenograms with a magnifying glass renders the same diagnostic possibilities.

Article History

Accepted: May 1965
Published in print: Aug 1965