Scand J Rheumatology 5: 113-1 18, 1976
SOFT TISSUE RADIOGRAPHY OF THE HANDS IN THE RHEUMATOID ARTHRITIS P. Makela and M. Haataja
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
From the Department of Diagnostic Radiology and Medicine, Turku University Hospital, Turku, Finland
ABSTRACT. 25 cases of rheumatoid arthritis were investigated radiologicallyand clinically over a perlod of 3 months, using soft tissue radiograms of the hands and Lansbury’s Activity Index. The soft tissue radiography technique was a new combination using molybdenum target mammographic equipment and immersion of the hands in a 2.5 cm layer of 1 :1 ethanol-water solution, in order to reduce the uneven darkening of films. Periarticular oedema and progression of erosive and soft tissue changes were observed in clinically active cases. High scores for joint swelling and erosions were also registered in some clinically inactive cases. Determinationof the rapid progressionof erosive and soft tissue changes and the determination of periarticular hyperaemic oedema using special radiographic methods appear to be of some value in assessing the activity of rheumatoid arthritis.
The techniques available for assessing the activity of the disease process in rheumatoid arthritis (RA) are inexact, largely because the basic nature of the disease is unknown. Joint inflammation findings occupy a prominent place in all methods of assessment, but even such obvious parameters as tenderness, pain, swelling, warmth, redness and range of motion are difficult to estimate quantitatively. Various numerical systems have therefore been developed to evaluate both the articular and the systemic activity of the disease. One of the most popular activity indexes has been devised by Lansbury (7). It is based on three subjective criteria: morning stiffness, fatigue, and aspirin need; one semi-objective parameter: grip strength; and two wholly objective parameters: Westergren sedimentation rate and Articular Index. This latter item is based on joint tenderness to pressure or passive movement and the size of the joints involved. Lansbury’s activity index makes great demands on the physician’s time and is not suitable for routine 8-761866
use in many hospitals. If instead the estimation of the activity is based on routine laboratory findings ( 5 ) or radiological investigations, then many examinations of the patient can be omitted and the examiner’s or patient’s subjective influence is not involved. The radiological manifestations of RA reflect the pathological changes of the disease. X-ray findings are a valuable complement to the clinical diagnosis. The irreversible nature of bone changes and joint destruction favour long-term trials for the scoring of the extent of structural changes. The quantitative assessment of the progression of radiologic abnormalities has been shown to be of prognostic value (12). The correlation between the progression of erosive changes and the clinical features of the disease has been studied by Karten et al. (6). During the follow-up period, which ranged between 11 and 40 months, progression of erosive changes was also observed in the clinically inactive cases but the correlation between clinical activity and progression of erosions was not statistically significant. The importance of radiologic soft tissue changes has often been stressed, and their significance in the early diagnosis of RA has been discussed (1, 2, 13). The development of soft tissue radiographic techniques, especially in the field of mammography, has led to new developments in the radiography of thin body sections such as hands and feet. Weiss described a technique for visualizing the tine detail in bones of the hands (14). New diagnostic applications in soft tissue radiography of the extremities have been investigated (3, 4, 10). An immersion technique has been used for the demonstration of early changes in metabolic and systemic disorders Scand J Rheumatology 5
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114
P . Miikelii and M . Hautuja
Fig. 1. ( a ) Left hand of a patient with a Lansbury Index of over 101. Numerous moderately swollen joints, many erosive changes. (b) Same hand 3 months later, no changes in
Scand J Rheumatology 5
articular swellings; rapid progression of erosive changes has occurred especially in metacarpophalangeal joints.
Soft tissue radiography of the hands Table I
Lansbury Index Sex
Age
Duration of disease (y.)
Progressionof erosive changes
&I 1-3 3 3 3 &I 3
3 12 2 0 0
Progression of soft tissue changes
~~
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
106 101 101
102 89 89 74 74 68 61 58 50 45 45 34 42 35 30 26 23 20 30 20 8 0
F F F F F
48 28 53 53 45 M 34 F 46 F 64 F 56 F 44 F 43 F 6 6 F 62 F 60 F 63 F 71 M 40 F 40 F 36 M 31 F 53 F 44 F 37 M 52 M 30
CI
3 3 3 3 1-3 3 3 &I 3 3 1-3 3 1-3 3 &I 3 3
0 0
4 0 3 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
1 1
2 0 0 2 0 0 0 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(15). A combination of mammographic and immersion techniques appears to have some value in detecting the pathological soft tissue changes of RA in the hands, This technique also provides great resolving power for revealing tine bone detail (9). The main purpose of the present investigation was to determine the presence of new soft tissue or bone changes in relative short-term radiological controls, using soft tissue roentgenograms of the hands. It was also intended to examine possible correlations between radiologic soft tissue changes and the clinical activity of rheumatoid disease.
MATERIALS AND METHODS Twenty-five patients from the Centre for Rheumatoid Diseases in Turku were selected for this study. All had definite rheumatoid arthritis (RA) ( 1 1) with a duration of
Fig. 2. ( a ) Right hand of a patient with a Lansbury Index of over 100. Only moderate joint swelling and a few erosive changes. Extra-articular oedema, especially in the region of fingers I1 and 111. (b) Same hand 3 months later. Abatement of the oedema after therapy is clearly visible.
I15
less thdn 6 years, and all were known to have had symptoms of this disease involving their hands during the last 3 years. Five of the patients were men. All patients with active symptoms received medical therapy during the follow-up period. Only a small minority had been inpatients for some part of the observation period. The clinical investigation of patients consisted of assessing the extent of the disease activity according to Lansbury’s Index and also the local articular status of the hands, with local pressure pain and soft tissue swelling being regarded as clinical signs of the synovitis. Soft tissue radiography of hands was performed using the following technique. The hands of the patient were immersed in a 2.5 cm layer of a 1 : I water-ethanol mixture in a perspex tray. The (Senographe-CGR@) mammography apparatus with stationary molybdenum anode, focus 0.6 mm, was used, filtration exposure factors were 30 kVp, 9&150 mA, exposure time 3-5 sec, anode-film distance 40 crn. Kodak Pe 4006 mammography film was processed for 3.5 min in a roll film processor (PAKOm) using 3M chemicals. The interpretation of the radiograms was made without prior knowledge of the clinical status. No enlargement technique was used. The clinical and radiological investigations were repeated about 3 months later. Special attention was paid to new soft tissue and bone changes. The radiologic abnormalities were also scored at the first investigation. Joint swelling was classified into four groups: O=no swelling. l=slight swelling, 2=moderate swelling, 3=massive swelling. All proximal interphalangeal and metacarpophalangeal joints and the ra-
Table I1 Lansbury Index
Periarticular oedema
106 101 101
4 4 I2
I02 89 89 74 74 68 61 58 50 45
5
45
34 42 35 30 26 23 20 30 20 8 0
Joint swelling
Erosion
2
17 23 19 38 9
5
14
2
4 7 0 3 0
12 32 I2 13
14
7
1
9
2 2 0 0 0
17
0 0 0 0 0 0 0 0
22 10 10
20 0
5 43 0 39 10
25 13 5 3 2 26 14 2 6 38
5
3 0 Scand J Rheumalology 5
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116
P . Makelu and M . Haataja
Fig. 3 . ( a ) Fourth finger of the right hand of a patient with a Lansbury Index of over 60. Proximal interphalangeal joint has a slight soft tissue swelling and slight subperiosteal osteoporosis on the radial side of the head of the
proximal phalanx. Joint was otherwise symptomless. ( b ) Same joint 3 months later. A new usuration at the site of the former subperiosteal osteoporosis.
dial and ulnar sides of the wrists were investigated. The highest possible joint swelling score was thus 66. The scoring Of penarticular CEXkma was performed by counting the number of joints with blurred surroundings. The highest possible score for joint oedema was therefore 22. The same joints were evaluated for the presence of erosions, and the Scoring Was as fOiiOWS. O = n O erosion, 1 =suspected erosion or subperiosteal local osteolytic area, 2=one erosion, 3=two or more erosions in the joint. The Dossible erosion was 66. The total number of examined joints was 550.
RESULTS
Srund J Rhertmurologv 5
N e w erosive changes or enlargement of existing erosions were seen in 5 cases (Fig. 1 a , b ) and 4 of these showed new soft tissue swelling. In one case a noticeable reduction ofjoint swelling was observed. Table I lists the Lansbury Indices of the patients at the time of the first investigation, their sex, age, duration of the disease and the number of new erosive and soft tissue changes during the observation
Soft tissue rudiogruphy of rhe hands
117
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
tion of new erosive changes. Clinical signs of local synovitic activity were also absent in some joints where progression of radiological erosive changes was noticed (Fig. 3 0 , b). Radiologically it was not possible to differentiate between synovial thickening and intra-articular hydroptic fluid without arthrography-even by our method. In one case a chronic fluctuating hydroptic swelling of IV PIP joint was roentgenologically indistinguishable from a very prominent nodular synovial joint swelling (Fig. 4). DISCUSSION
Fig. 4. Left fourth proximal interphalangeal joint of a women patient with a Lansbury Index of below 50. Radiologically, a prominent soft tissue joint swelling was apparent. On clinical examination the joint was noticed to be tilled with hydroptic fluid and anamnestically the situation had been the same for over 3 years in this joint.
period. All these new changes appeared in patients with a Lansbury Index of over 60. Of 10 patients with an Index exceeding 60,6 showed new changes. Three of 4 patients with an Index of over 100 showed new changes. Periarticular oedema was observed in all but one of the 10 patients who had Lansbury lndex of over 60. Oedema was present in only 3 of the I5 patients having an Index of less than 60. High scores for joint swelling and for erosions were observed in patients who had a low lndex and low scores were present in patients who had high Activity Indices. Table I1 shows Indices and various corresponding scores. A close correlation between local clinical and roentgenological findings was observed. This correlation was closest in the recognition of PIP joint swelling. I n MCP, joint swelling was found more often radiologically than clinically. During the second investigation with some patients the joint swelling was clinically regarded as having changed, yet without showing any corresponding appreciable radioloeical changes. All joints where progression of erosive changes appeared had some joint swelling, but neither appearance of joint swelling nor Periarticular edema was of any value as a means of predicting the locaY
-
In the presence of active RA, progression of erosive changes may develop quite rapidly. The demonstration of small radiological difference in erosions necessitates a method having a superior resolution. One such method is the mammographic one using a molybdenum target and industrial film. This method provides us with information about the status of the soft tissue parts. Its applications, however, are limited to those parts of the body with a thickness of less than 10 cm. To obtain a uniform darkening in body parts with great variations in thickness, the immersion method can be of advantage. Demonstration of periarticular oedema or blurring of joint surroundings appears to be valuable in the radiological assessment of the activity of RA. The blurring of joint surroundings results partially from hyperaemia in the joint area. This principle is also utilized in thermography and synovial membrane scanning for the determination of joint inflammation activity (8). Scoring of the extent of joint swelling does not appear to be as good a method for determining the extent of disease activitY.
The demonstration of periarticular oedema has its methodological sources of error. Slight blurring created by movement may be mistaken for oedema. Advanced cases of RA may show areas of chronic lymphatic oedema, which seems not to be a sign of actual rheumatoid activity (9).
REFERENCES
D.L., Lockie, L. M., Lin, R. & Norcross, B. M.: Roentgen changes in early rheumatoid arthritis. Radiology82: 645, 1964. 2. Ferguson, A. B.: Roentgenographic features of rheumatoid arthritis. J Bone Joint Surg 18: 297, 1936. 1. Berens,
Scand J Rheumurology 5
118
P. Makela and M . Haataja
3. Fischer, E. & Braun, J.:
4.
5.
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
6.
7.
8. 9.
10.
Neue diagnostische Moglichkeiten an den Extramitaten durch Weichstrahlaufnahmen mit Mamrnographiegeraten. Electromedica3: 90,1973. Fischer, E.: Die Rontgenologische Weichteildiagnostik der Rheumatischen Arthritis. (Weichstrahlaufnahmen der Hand.) In Frommhold/Gerrhard Klinisch-radiologischer Seminar, Band 3. ThiemeStuttgart, 1973. Haataja, M.: Evaluation of the activity of rheumatoid arthritis. Scand J Rheuml: Suppl. 7. 1975. Karten, I., OBrien, W. M., Becker, M. H. & McEven, C.: Articular erosion in rheumatoid arthritis. J Cron Dis52: 449, 1972. Lansbury, J.: Methods for evaluating rheumatoid arthritis. In Arthritis and Allied Conditions (ed. J. C. Hollander), 7th ed., pp. 269-291. Lea & Febiger, Philadelphia, 1966. Maxfiled, W. S., Weiss, T. E. & Shuler, S. E.: Synovial Membrane Scanning in Arthritis Disease. Seminars In Nuclear Medicine 12, no. 1. 1972. Makela, P., Kalliomaki, J. L. & Virtama, P.: Radiologic demonstration of connective tissue changes of hands in rheumatoid arthritis. Scand J Rheum-?: 110, 1974. Reichman, S., Deichgraber, E., Strid, K. G.,
Scand J Rheumalology 5
Heyman, F. & Strand, T.: Soft tissue radiography of finger joints. Acta Radio1 Diagn 15: 439, 1974. 11. Ropes, M. W., Bennet, G. A.. Cobb, S., Jacox, R. & Jessar, R. A. 1958 revision of diagnostic criteria for rheumatoid arthritis. Arthritis Rheum 2: 16, 1959. 12. Sharp, J. T., Lidsky, M. D., Collins, L. C. & Moreland, J.: Methods of scoring the progression of radiologic changes in rheumatoid arthritis. Arthritis Rheum 14: 706, 1971. 13. Soila, P.: Roentgen manifestations of adult rheumatoid arthritis. Acta Rheum Scand, Suppl. 1, 1958. 14. Weiss, A.: A technique for demonstrating fine detail in bones of the hands. Clin Radiol23: 185, 1972. 15. Walker, B. Q.: Use of high definitation films and im-
mersion technic in early diagnosis of metabolic and systemic disorders. Cleveland Clin Quart 31: 227, 1964. Submitted for publication August 22, 1975
P. Makela Dept. of Diagnostic Radiology Turku University Hospital Turku Finland
SOFT TISSUE RADIOGRAPHY OF THE HANDS IN THE RHEUMATOID ARTHRITIS P. Makela and M. Haataja
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
From the Department of Diagnostic Radiology and Medicine, Turku University Hospital, Turku, Finland
ABSTRACT. 25 cases of rheumatoid arthritis were investigated radiologicallyand clinically over a perlod of 3 months, using soft tissue radiograms of the hands and Lansbury’s Activity Index. The soft tissue radiography technique was a new combination using molybdenum target mammographic equipment and immersion of the hands in a 2.5 cm layer of 1 :1 ethanol-water solution, in order to reduce the uneven darkening of films. Periarticular oedema and progression of erosive and soft tissue changes were observed in clinically active cases. High scores for joint swelling and erosions were also registered in some clinically inactive cases. Determinationof the rapid progressionof erosive and soft tissue changes and the determination of periarticular hyperaemic oedema using special radiographic methods appear to be of some value in assessing the activity of rheumatoid arthritis.
The techniques available for assessing the activity of the disease process in rheumatoid arthritis (RA) are inexact, largely because the basic nature of the disease is unknown. Joint inflammation findings occupy a prominent place in all methods of assessment, but even such obvious parameters as tenderness, pain, swelling, warmth, redness and range of motion are difficult to estimate quantitatively. Various numerical systems have therefore been developed to evaluate both the articular and the systemic activity of the disease. One of the most popular activity indexes has been devised by Lansbury (7). It is based on three subjective criteria: morning stiffness, fatigue, and aspirin need; one semi-objective parameter: grip strength; and two wholly objective parameters: Westergren sedimentation rate and Articular Index. This latter item is based on joint tenderness to pressure or passive movement and the size of the joints involved. Lansbury’s activity index makes great demands on the physician’s time and is not suitable for routine 8-761866
use in many hospitals. If instead the estimation of the activity is based on routine laboratory findings ( 5 ) or radiological investigations, then many examinations of the patient can be omitted and the examiner’s or patient’s subjective influence is not involved. The radiological manifestations of RA reflect the pathological changes of the disease. X-ray findings are a valuable complement to the clinical diagnosis. The irreversible nature of bone changes and joint destruction favour long-term trials for the scoring of the extent of structural changes. The quantitative assessment of the progression of radiologic abnormalities has been shown to be of prognostic value (12). The correlation between the progression of erosive changes and the clinical features of the disease has been studied by Karten et al. (6). During the follow-up period, which ranged between 11 and 40 months, progression of erosive changes was also observed in the clinically inactive cases but the correlation between clinical activity and progression of erosions was not statistically significant. The importance of radiologic soft tissue changes has often been stressed, and their significance in the early diagnosis of RA has been discussed (1, 2, 13). The development of soft tissue radiographic techniques, especially in the field of mammography, has led to new developments in the radiography of thin body sections such as hands and feet. Weiss described a technique for visualizing the tine detail in bones of the hands (14). New diagnostic applications in soft tissue radiography of the extremities have been investigated (3, 4, 10). An immersion technique has been used for the demonstration of early changes in metabolic and systemic disorders Scand J Rheumatology 5
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
114
P . Miikelii and M . Hautuja
Fig. 1. ( a ) Left hand of a patient with a Lansbury Index of over 101. Numerous moderately swollen joints, many erosive changes. (b) Same hand 3 months later, no changes in
Scand J Rheumatology 5
articular swellings; rapid progression of erosive changes has occurred especially in metacarpophalangeal joints.
Soft tissue radiography of the hands Table I
Lansbury Index Sex
Age
Duration of disease (y.)
Progressionof erosive changes
&I 1-3 3 3 3 &I 3
3 12 2 0 0
Progression of soft tissue changes
~~
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
106 101 101
102 89 89 74 74 68 61 58 50 45 45 34 42 35 30 26 23 20 30 20 8 0
F F F F F
48 28 53 53 45 M 34 F 46 F 64 F 56 F 44 F 43 F 6 6 F 62 F 60 F 63 F 71 M 40 F 40 F 36 M 31 F 53 F 44 F 37 M 52 M 30
CI
3 3 3 3 1-3 3 3 &I 3 3 1-3 3 1-3 3 &I 3 3
0 0
4 0 3 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
1 1
2 0 0 2 0 0 0 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(15). A combination of mammographic and immersion techniques appears to have some value in detecting the pathological soft tissue changes of RA in the hands, This technique also provides great resolving power for revealing tine bone detail (9). The main purpose of the present investigation was to determine the presence of new soft tissue or bone changes in relative short-term radiological controls, using soft tissue roentgenograms of the hands. It was also intended to examine possible correlations between radiologic soft tissue changes and the clinical activity of rheumatoid disease.
MATERIALS AND METHODS Twenty-five patients from the Centre for Rheumatoid Diseases in Turku were selected for this study. All had definite rheumatoid arthritis (RA) ( 1 1) with a duration of
Fig. 2. ( a ) Right hand of a patient with a Lansbury Index of over 100. Only moderate joint swelling and a few erosive changes. Extra-articular oedema, especially in the region of fingers I1 and 111. (b) Same hand 3 months later. Abatement of the oedema after therapy is clearly visible.
I15
less thdn 6 years, and all were known to have had symptoms of this disease involving their hands during the last 3 years. Five of the patients were men. All patients with active symptoms received medical therapy during the follow-up period. Only a small minority had been inpatients for some part of the observation period. The clinical investigation of patients consisted of assessing the extent of the disease activity according to Lansbury’s Index and also the local articular status of the hands, with local pressure pain and soft tissue swelling being regarded as clinical signs of the synovitis. Soft tissue radiography of hands was performed using the following technique. The hands of the patient were immersed in a 2.5 cm layer of a 1 : I water-ethanol mixture in a perspex tray. The (Senographe-CGR@) mammography apparatus with stationary molybdenum anode, focus 0.6 mm, was used, filtration exposure factors were 30 kVp, 9&150 mA, exposure time 3-5 sec, anode-film distance 40 crn. Kodak Pe 4006 mammography film was processed for 3.5 min in a roll film processor (PAKOm) using 3M chemicals. The interpretation of the radiograms was made without prior knowledge of the clinical status. No enlargement technique was used. The clinical and radiological investigations were repeated about 3 months later. Special attention was paid to new soft tissue and bone changes. The radiologic abnormalities were also scored at the first investigation. Joint swelling was classified into four groups: O=no swelling. l=slight swelling, 2=moderate swelling, 3=massive swelling. All proximal interphalangeal and metacarpophalangeal joints and the ra-
Table I1 Lansbury Index
Periarticular oedema
106 101 101
4 4 I2
I02 89 89 74 74 68 61 58 50 45
5
45
34 42 35 30 26 23 20 30 20 8 0
Joint swelling
Erosion
2
17 23 19 38 9
5
14
2
4 7 0 3 0
12 32 I2 13
14
7
1
9
2 2 0 0 0
17
0 0 0 0 0 0 0 0
22 10 10
20 0
5 43 0 39 10
25 13 5 3 2 26 14 2 6 38
5
3 0 Scand J Rheumalology 5
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116
P . Makelu and M . Haataja
Fig. 3 . ( a ) Fourth finger of the right hand of a patient with a Lansbury Index of over 60. Proximal interphalangeal joint has a slight soft tissue swelling and slight subperiosteal osteoporosis on the radial side of the head of the
proximal phalanx. Joint was otherwise symptomless. ( b ) Same joint 3 months later. A new usuration at the site of the former subperiosteal osteoporosis.
dial and ulnar sides of the wrists were investigated. The highest possible joint swelling score was thus 66. The scoring Of penarticular CEXkma was performed by counting the number of joints with blurred surroundings. The highest possible score for joint oedema was therefore 22. The same joints were evaluated for the presence of erosions, and the Scoring Was as fOiiOWS. O = n O erosion, 1 =suspected erosion or subperiosteal local osteolytic area, 2=one erosion, 3=two or more erosions in the joint. The Dossible erosion was 66. The total number of examined joints was 550.
RESULTS
Srund J Rhertmurologv 5
N e w erosive changes or enlargement of existing erosions were seen in 5 cases (Fig. 1 a , b ) and 4 of these showed new soft tissue swelling. In one case a noticeable reduction ofjoint swelling was observed. Table I lists the Lansbury Indices of the patients at the time of the first investigation, their sex, age, duration of the disease and the number of new erosive and soft tissue changes during the observation
Soft tissue rudiogruphy of rhe hands
117
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
tion of new erosive changes. Clinical signs of local synovitic activity were also absent in some joints where progression of radiological erosive changes was noticed (Fig. 3 0 , b). Radiologically it was not possible to differentiate between synovial thickening and intra-articular hydroptic fluid without arthrography-even by our method. In one case a chronic fluctuating hydroptic swelling of IV PIP joint was roentgenologically indistinguishable from a very prominent nodular synovial joint swelling (Fig. 4). DISCUSSION
Fig. 4. Left fourth proximal interphalangeal joint of a women patient with a Lansbury Index of below 50. Radiologically, a prominent soft tissue joint swelling was apparent. On clinical examination the joint was noticed to be tilled with hydroptic fluid and anamnestically the situation had been the same for over 3 years in this joint.
period. All these new changes appeared in patients with a Lansbury Index of over 60. Of 10 patients with an Index exceeding 60,6 showed new changes. Three of 4 patients with an Index of over 100 showed new changes. Periarticular oedema was observed in all but one of the 10 patients who had Lansbury lndex of over 60. Oedema was present in only 3 of the I5 patients having an Index of less than 60. High scores for joint swelling and for erosions were observed in patients who had a low lndex and low scores were present in patients who had high Activity Indices. Table I1 shows Indices and various corresponding scores. A close correlation between local clinical and roentgenological findings was observed. This correlation was closest in the recognition of PIP joint swelling. I n MCP, joint swelling was found more often radiologically than clinically. During the second investigation with some patients the joint swelling was clinically regarded as having changed, yet without showing any corresponding appreciable radioloeical changes. All joints where progression of erosive changes appeared had some joint swelling, but neither appearance of joint swelling nor Periarticular edema was of any value as a means of predicting the locaY
-
In the presence of active RA, progression of erosive changes may develop quite rapidly. The demonstration of small radiological difference in erosions necessitates a method having a superior resolution. One such method is the mammographic one using a molybdenum target and industrial film. This method provides us with information about the status of the soft tissue parts. Its applications, however, are limited to those parts of the body with a thickness of less than 10 cm. To obtain a uniform darkening in body parts with great variations in thickness, the immersion method can be of advantage. Demonstration of periarticular oedema or blurring of joint surroundings appears to be valuable in the radiological assessment of the activity of RA. The blurring of joint surroundings results partially from hyperaemia in the joint area. This principle is also utilized in thermography and synovial membrane scanning for the determination of joint inflammation activity (8). Scoring of the extent of joint swelling does not appear to be as good a method for determining the extent of disease activitY.
The demonstration of periarticular oedema has its methodological sources of error. Slight blurring created by movement may be mistaken for oedema. Advanced cases of RA may show areas of chronic lymphatic oedema, which seems not to be a sign of actual rheumatoid activity (9).
REFERENCES
D.L., Lockie, L. M., Lin, R. & Norcross, B. M.: Roentgen changes in early rheumatoid arthritis. Radiology82: 645, 1964. 2. Ferguson, A. B.: Roentgenographic features of rheumatoid arthritis. J Bone Joint Surg 18: 297, 1936. 1. Berens,
Scand J Rheumurology 5
118
P. Makela and M . Haataja
3. Fischer, E. & Braun, J.:
4.
5.
Scand J Rheumatol Downloaded from informahealthcare.com by Freie Universitaet Berlin on 11/26/14 For personal use only.
6.
7.
8. 9.
10.
Neue diagnostische Moglichkeiten an den Extramitaten durch Weichstrahlaufnahmen mit Mamrnographiegeraten. Electromedica3: 90,1973. Fischer, E.: Die Rontgenologische Weichteildiagnostik der Rheumatischen Arthritis. (Weichstrahlaufnahmen der Hand.) In Frommhold/Gerrhard Klinisch-radiologischer Seminar, Band 3. ThiemeStuttgart, 1973. Haataja, M.: Evaluation of the activity of rheumatoid arthritis. Scand J Rheuml: Suppl. 7. 1975. Karten, I., OBrien, W. M., Becker, M. H. & McEven, C.: Articular erosion in rheumatoid arthritis. J Cron Dis52: 449, 1972. Lansbury, J.: Methods for evaluating rheumatoid arthritis. In Arthritis and Allied Conditions (ed. J. C. Hollander), 7th ed., pp. 269-291. Lea & Febiger, Philadelphia, 1966. Maxfiled, W. S., Weiss, T. E. & Shuler, S. E.: Synovial Membrane Scanning in Arthritis Disease. Seminars In Nuclear Medicine 12, no. 1. 1972. Makela, P., Kalliomaki, J. L. & Virtama, P.: Radiologic demonstration of connective tissue changes of hands in rheumatoid arthritis. Scand J Rheum-?: 110, 1974. Reichman, S., Deichgraber, E., Strid, K. G.,
Scand J Rheumalology 5
Heyman, F. & Strand, T.: Soft tissue radiography of finger joints. Acta Radio1 Diagn 15: 439, 1974. 11. Ropes, M. W., Bennet, G. A.. Cobb, S., Jacox, R. & Jessar, R. A. 1958 revision of diagnostic criteria for rheumatoid arthritis. Arthritis Rheum 2: 16, 1959. 12. Sharp, J. T., Lidsky, M. D., Collins, L. C. & Moreland, J.: Methods of scoring the progression of radiologic changes in rheumatoid arthritis. Arthritis Rheum 14: 706, 1971. 13. Soila, P.: Roentgen manifestations of adult rheumatoid arthritis. Acta Rheum Scand, Suppl. 1, 1958. 14. Weiss, A.: A technique for demonstrating fine detail in bones of the hands. Clin Radiol23: 185, 1972. 15. Walker, B. Q.: Use of high definitation films and im-
mersion technic in early diagnosis of metabolic and systemic disorders. Cleveland Clin Quart 31: 227, 1964. Submitted for publication August 22, 1975
P. Makela Dept. of Diagnostic Radiology Turku University Hospital Turku Finland
