Earliest Roentgen Changes in Polyarthritis of the Rheumatoid Type
In 1963 (1) and 1965 (2) it was first announced that hitherto unnoticed, very early and yet significant roentgen changes in polyarthritis could be demonstrated. Since then, these changes have formed the basis for diagnosis and treatment of several hundred cases of early polyarthritis in our hospital, fulfilling our expectations of their significance.
In 1966 Clemmesen (3) published a clinical critique of the diagnostic value of these earliest roentgen changes dorsoradial on the proximal end of the first phalanx of the four ulnar fingers as compared with hitherto applied clinical and serologic criteria for rheumatoid polyarthritis. Of 100 consecutive patients in whom polyarthritis of the rheumatoid type was clinically established according to the criteria set up by the American Rheumatism Association, the duration of disease in all cases being short (one month to two years), characteristic roentgen changes had been demonstrated at the initial x-ray examination in no less than 89. At the same time the blood sedimentation reaction had also increased in 89 cases—although not always in the 89 with positive roentgen findings—whereas the more specific seroreactions proved positive in even less than 50 per cent of the cases.
In the first reports about the early digital roentgen changes in polyarthritis it was emphasized that similar early contour defects were likely to be present in other joints. At that time, however, perhaps because of anatomic or technical difficulties, it had been feasible to demonstrate such slight changes in only a couple of sites in a limited number of cases.
We have been of the opinion that the value of the demonstration of the earliest roentgen changes is greatly dependent on an easily applicable technic which facilitates comparison under all circumstances. At every primary examination we have therefore made it routine to use the three simple exposures mentioned earlier (1, 2), i.e., one frontal dorsovolar view of both hands and wrists, one of both hands and wrists in a halfway supinate position, and one dorsoplantar projection of both forefeet.
Owing to purely anatomic and technical reasons the changes dorsoradially in the proximal phalanges of the four ulnar fingers (now called the digital earliest roentgen changes) were the first to be recognized. From a diagnostic point of view they must be considered the most reliable and—to the inexperienced—the easiest to recognize purely because projections will actually permit comparison at one and the same time of no less than 4 pairs of completely uniform joints of extremely simple, regular anatomic structure. Here very early changes will only seldom appear simultaneously in all 4 pairs (Fig. 1), so that slight pathologic changes may be compared straightaway with the normal picture.