Determination of the stages of rheumatoid arthritis by radiological signs

Classification of the disease by radiological stages

The pathogenetic mechanism for the development of rheumatoid arthritis is an autoimmune cross-reaction. The antigenic structure of hemolytic streptococcus, belonging to group B, is similar in structure to the connective tissue of the human body.

When infected with a microorganism (acute or chronic tonsillitis, pyelonephritis, intestinal pathology), the produced antibodies may damage one's own tissues. The joints are the first to suffer. With each new rheumatic attack, the affected area expands and the changes become irreversible and severe.

In the early stages, at the first signs, changes may not be detected on an x-ray. But the further the process progresses, the more obvious the damage becomes. There are four radiographic stages of pathology.

First stage

The first stage is characterized as the easiest, the changes are reversible and treatable. Clinically, the patient complains of morning stiffness in the movements of the hands, swelling is visually noted in the area of the small joints of the fingers. More often, the symptoms are associated with a recent infectious pathology (sore throat, tonsillitis, urinary tract infection, streptoderma, etc.).

First stage
The small joints of the hands and feet are the first to suffer. X-ray signs of the first stage of rheumatoid arthritis:

predominant inflammation of the soft tissue component, which has the form of compaction of structures above the affected joint;
slight narrowing of the interarticular space, which is not visualized on an x-ray;
initial manifestations of osteoporosis in the form of local clearing of bone structures and loosening of only the articular surfaces.

Second stage

Clinically, the second stage manifests itself in the form of severe stiffness of the hands for several hours, mainly in the morning and evening. The changes are more pronounced, manifested in the form of swelling and visible deformation, manipulative movements of the hands are significantly difficult (it is difficult for the patient to thread a button into a buttonhole, a thread into a needle, or tie shoelaces).

Second stage
In the area of the joints, a seal is palpated, skin manifestations in the form of rheumatoid nodules are often added, the skin over them is hyperemic. Pain in the legs is acute, walking is difficult, and lameness is observed.

The second radiographic stage of the disease is divided into two subgroups, depending on the degree of damage in the form of erosion of the articular surface:

Is arthritis visible on an x-ray, and how to interpret the image?

subgroup A of the second radiological stage is characterized by the absence of erosions on the articular surfaces; the image reveals periarticular osteoporosis in the form of cysts (local clearing of bone structures), areas of bone compaction and a more noticeable narrowing of the gap between the articular surfaces;
subgroup B of the second radiological stage of the pathology, in addition to the main manifestations, is characterized by the appearance of erosions of the surfaces of the joints, in no more than four places.

Third stage

Clinically characterized by complete immobility of small joints. The pathology extends to large ones: wrist, elbow, knee, ankle, upper shoulder girdle and even intervertebral joints in rare cases. The patient experiences difficulty walking due to severe pain and stiffness of the knee joints.

Third stage
Deformation of the hands occurs in the form of a “walrus fin” (subluxation of the metacarpophalangeal joints) or “swan neck” (formation of persistent flexion contractures of the metacarpophalangeal joints and hyperextension of the interphalangeal joints), inability to abduct the thumb. The patient cannot perform simple manipulative actions with his hands, including difficulty holding a cup, spoon, etc.

Bones become fragile due to a pronounced degenerative process. Cases of subluxations, dislocations, and pathological fractures are becoming more frequent. Healing of damage takes a long time and requires surgical interventions.

Third degree of rheumatoid arthritis on x-ray:

formation of a single bone block in the area of small joints of the hands;
more than 5 areas of bone tissue erosion;
narrowing of the joint spaces of small and large joints;
the appearance of osteoporotic cysts;
the formation of soft tissue calcifications (rheumatoid nodules), which in the image appear as rounded areas of darkening, up to 2 cm in diameter, in the area of the soft tissue component around the joints (usually the hands, elbows, knees).

Fourth stage

The terminal stage of the rheumatoid process, which irreversibly disables the patient. Performing simple everyday activities is impossible due to severe pain and persistent joint contractures (immobility). The patient's muscles atrophy due to lack of movement. A person cannot take care of himself (eat, go to the toilet) and requires regular assistance.

Fourth stage
Based on the results of radiography of the joints, the following changes are revealed:

absence of joint space with compaction in the articulation area and the formation of ankylosis (joint contractures) and subchondral osteosclerosis (due to increased friction of cartilaginous structures in the absence of joint space, they calcify and sclerosis, become dense, lose shock-absorbing capabilities);
bone growths are formed on the articular surfaces - osteophytes, which have a pointed shape;
osteoporosis can develop into osteonecrosis.

Symptoms

The initial stage of the disease has virtually no obvious symptoms. Over time, slight stiffness appears in the affected joints. As a rule, it occurs in the morning, as the secretion of glucocorticoids decreases. It is difficult for the patient to move, movements are inhibited. Sometimes you need help getting up. But after 30 minutes - an hour everything returns to normal. The clinic can be rolled out over several months or even years, gradually intensifying.

Primary symptoms also include:

periodic joint pain;
loss of appetite;
increased fatigue.

Second stage

characterized by rapid cell division and thickening of the synovial membrane. There is symmetrical swelling of the joints, the skin in the affected areas has an increased temperature. Sudden pain is also observed, intensifying with active movement. To complete the process, they need the same amount of rest time that was spent moving.

Third stage

― active phase of inflammation involving cartilage and bones. The affected joints begin to deform, which leads to increased pain and loss of motor function.

Rheumatoid arthritis often has concomitant joint diseases, and vague symptoms make differential diagnosis difficult. Among the most beneficial combinations are rheumatism, osteoarthritis and other systemic pathologies of connective tissue. The only specific manifestation of rheumatoid arthritis can be called nodules, so-called subcutaneous formations on the extensor surface. They can be detected by palpation.

Extra-articular manifestations of RA

Pathological processes caused by rheumatoid arthritis that occur outside the joints occur in a third of patients. These symptoms also complicate diagnosis and influence the choice of treatment tactics. Among them:

Cutaneous vasculitis (ulcerative-necrotic, livedoangiitis, infarction of the nail bed).
Sjogren's syndrome (damage to the salivary and lacrimal glands).
Eye lesions (scleritis - inflammation of the deep layer of the eye, episcleritis - inflammation of the connective tissue of the eye).
Interstitial lung disease (inflammation of the alveoli, pulmonary capillaries and other tissues).

As a result of inflammation accompanying rheumatoid arthritis, pathologies of the cardiovascular, respiratory, and nervous systems may occur. The most serious complication is AA amyloidosis, which causes kidney failure.

Separately, it is worth highlighting various associated diseases that are not directly caused, but are associated with RA. These are coronary heart disease, thromboembolism, anemia, psychoneurological disorders, among which depression deserves attention. Like any other autoimmune disease with chronic inflammation, rheumatoid arthritis affects psychological well-being. The patient is recommended to undergo psychological courses and a comprehensive, comprehensive examination.

Bone erosion in pathology

Erosion of bone structures is divided into three types:

Marginal or superficial - detected already at the second stage in joints where there is no cartilaginous structure and friction is more severe.
Compression - occurs due to aggravation of the process and failure of the bone at the site of injury.
Deforming - formed due to the destruction of the bone plate, visible bone deformation is visually observed, characteristic of stage 4 of pathology.

Single erosions of the bones of the wrist
When bone erosions occur, it is practically impossible to cure the disease. Long-term multicomponent therapy only helps to stop the progressive process.

Treatment and prevention of rheumatoid arthritis

The pathology is treated by a rheumatologist. Treatment of the disease is complex and multicomponent:

Diet therapy. The diet should be dominated by foods rich in calcium (milk, cottage cheese, fresh vegetables and herbs); if you are overweight, there is a need to lose weight to reduce the load on the joints of the lower extremities. Products that help maintain cartilaginous structures are also useful: jelly, agar-agar, jellied meat, jellied fish.
Drug treatment.
Pathogenetic therapy. Non-steroidal anti-inflammatory drugs (Diclofenac, Nimesil) and steroids (Prednisolone, Dexamethasone) are prescribed; they help relieve pain and reduce inflammation. To prevent the autoimmune process, cytostatics (Methotrexate, Cyclosporine) and biological drugs (Rituximab, Enbrel) are prescribed.
Etiotropic therapy. Antibacterial agents (Bicillin) are used to prevent relapse of streptococcal infection.
Symptomatic therapy. Includes the use of chondroitin preparations and hyaluronic acid preparations to maintain cartilage structures, calcium with vitamin D3.
Physiotherapy and therapeutic exercises. Allows, with the help of physical exercises, electrophoresis, magnetic therapy, to improve hemodynamics in the affected area and activate regeneration processes.
Operative methods. They are used in extreme radiological stages (third and fourth) in the presence of dislocations, contractures and ankylosis, and pathological fractures.

Prevention of rheumatoid arthritis is the timely and correct treatment of infectious diseases and the prevention of the appearance of chronic lesions. In the initial stages (1-2), it is necessary to develop fine motor skills of the hands and arms - this helps to avoid permanent changes due to normal hemodynamics.

Such patients are recommended to start embroidering, knitting, and drawing. It is also necessary to eat properly to prevent degenerative pathologies of cartilage and bone structures.

Rheumatoid arthritis is a serious pathology that, at extreme stages of development, leads to disability of the patient. The disease can develop both in adulthood and in childhood. Progression leads to a deterioration in overall health and the appearance of persistent irreversible changes in the joint area.

X-ray of the wrist and hand: what is it and what does it show?

How effective is X-ray examination for RA?

Rheumatoid arthritis is commonly called an inflammatory disease of the joints, which is autoimmune (the immune system attacks the cells of its own body, mistakenly perceiving them as foreign and pathological). The reasons why this disease develops have not been precisely established. It is believed that RA can be triggered by:

infectious diseases previously suffered by a person;
exposure to toxic substances on the body;
frequent joint injuries;
constant hypothermia.

Risk factors include a family history of rheumatoid arthritis. As rheumatoid arthritis progresses, it primarily affects the small joints of the upper and lower extremities symmetrically. The pathological process immediately spreads to the synovial membrane, then to the cartilaginous tissue, eventually forming multiple erosions. The joints become deformed.

An X-ray examination allows the doctor to determine the degree of damage to the joints and determine how deformed the bone and cartilage tissues are. Using the image, the specialist counts the number of erosions that have formed in the bones.

In what cases is x-ray examination indicated and contraindicated?

An X-ray of the joints is prescribed to the patient if he has the following symptoms for a certain period of time:

pain in the joints;
limited joint mobility in the morning;
swelling in the area of the affected joint;
elevated rheumatoid factor detected in a blood test;
the presence of rheumatoid nodules (multiple subcutaneous nodular formations near bone structures);
deformation of the joints noticeable to the naked eye.

Since X-ray radiation is ionizing and can negatively affect the development of the embryo in the womb and small child, X-ray examination is not recommended for women during pregnancy and children. Patients who are in serious condition, suffering from epilepsy, acute and chronic mental illnesses are not examined. But the contraindications listed are relative.

If the attending physician decides that the benefit that radiography will bring to the patient by making a diagnosis will exceed the possible harm, he may, as an exception, prescribe the procedure.

Diagnostics

First of all, the doctor studies the clinical criteria for rheumatoid arthritis. The disease should be suspected in patients with symmetrical polyarthritis. Damage to the wrist, II and III metacarpophalangeal joints is important. It is necessary to exclude hepatitis C. Pay attention to the presence or absence of changes in skin color in inflamed joints, the presence of deformities of the limbs, tenosynovitis of the flexors or extensors of the fingers. Diagnostics also includes laboratory and instrumental results.

Laboratory research

The tasks of the laboratory include blood tests for RF, anti-CCP, ESR, and CRP. The most progressive analysis is the titer of antibodies to ACCP, anti-CCP, anti-CCP.

RF - analysis for antibodies to human gamma globulin is detected in 70% of RA patients. However, the indicator is not critical, since titers can be detected in other viral diseases and connective tissue pathologies. An RF test confirms rheumatoid arthritis in combination with a positive ACCP test.
ACCP is a test with high sensitivity reaching 86%. In combination with the RF titer, it indicates RA. However, it is necessary to exclude hepatitis C, since ACCP and RF titer may occur with this viral infection.

Additional tests include a biochemical blood test to determine the activity of inflammation. A general blood test to detect anemia, an immunological test to determine the presence of rheumatoid factor (IgM antibodies).

Instrumental diagnostics

X-ray examination. In the first months of the disease, radiography can only show soft tissue swelling. Marginal erosions, osteoporosis, and narrowing of the joint space are detected by the end of the first year of the disease or later.
Magnetic resonance imaging. The most informative research method at the moment. It allows you to identify early signs of inflammation, detect erosions and lesions of the subchondral bone.
Examination of synovial fluid. The procedure is carried out for exudative changes in the joints, to differentiate RA from arthritis of another nature. Cloudiness and yellowish color of the synovial fluid indicate the development of rheumatoid arthritis. The leukocyte count increases to 50,000/µl.

When making a diagnosis, it is important to exclude similar diseases: microcrystalline arthritis, sarcoidosis, reactive and psoriatic arthritis, systemic lupus erythematosus, osteoarthritis and other diseases.

Stages of RA according to Steinbrocker classification

In modern medical practice, the classification of stages of rheumatoid arthritis developed by Steinbrocker is most often used. He based his research on plain radiographs of the hands and distal feet, performed in a direct projection. With their help, it was possible to identify 4 radiological stages of rheumatoid arthritis, which reflect the nature of the progression of the disease.

Stage 1

This stage is the initial one. It is called periarticular osteoporosis (decreased bone density). The pathological process involves the joints of the hands and metatarsophalangeal joints of the feet. The x-ray visualizes the compaction of the soft tissues surrounding the joint. The bone tissue is thinned, loose, and has increased porosity (these are signs of osteoporosis). There are already cyst-like clearings in its structure. Among the radiological symptoms of the first stage of rheumatoid arthritis may be a narrowing of the joint space.

An appointment with a rheumatologist is necessary for a person who is faced with even a slight restriction of joint mobility in the morning (within approximately 1 hour after waking up). At the first stage, symptoms such as slight swelling of the tissues in the area of the affected joint and short-term pain in the joint during physical activity may also occur.

Periarticular osteoporosis occurs in both adults and children. The disease can progress rapidly, or it can stop in its development for several years and then become more active.

Stage 2

X-ray signs of rheumatoid arthritis at the beginning of the second stage are increased osteoporosis, multiple cysts in the structure of bone tissue, as well as a decrease in the lumen of joint spaces. This stage is called stage 2A, which lasts until the first erosion occurs, that is, bone damage. After this, stage 2B begins, continuing until a maximum of 4 eroded areas appear.

It is customary to classify all bone erosions into 3 categories:

Marginal superficial (formed in those areas where the articular bones are not covered with cartilaginous tissue).
Compression (accompanied by the failure of a section of bone due to the formation of a cyst and the progress of periarticular osteoporosis).
Erosion of the bone tissue of the endplates (appears where the joint connects to the ligaments).

The deformity of the hand or foot is not yet visible on an x-ray.

At the second stage of rheumatoid arthritis, the patient experiences limited joint mobility for several hours a day. During physical activity, pain increases.

Stage 3

This stage of disease development is characterized by the appearance of multiple erosions (from 5 pieces). The muscles around the affected joints atrophy. In addition to periarticular osteoporosis, decreased clearance of joint spaces, and cysts, X-ray signs of rheumatoid arthritis of the hands also include dislocations and subluxations of the joints, and their extended deformation. The most common types of deformities include:

"button loop";
"swan neck";
"walrus fin"

The images show signs of calcification (accumulation of excess calcium salts) in the soft tissues surrounding the affected joint. They are round and dense rheumatoid nodules, the diameter of which is from 2 to 3 cm.

When palpating them, the patient does not experience any painful sensations.

The level of density of calcifications varies, and this is clearly visible on the x-ray. At this stage of the disease, joint pain and immobility are so progressive that many activities require significant effort.

Stage 4

The last stage of RA is manifested by extensive osteoporosis, the spread of erosion not only to the surface of the joints, but also to other areas of bone tissue. The photographs clearly show that osteophytes (bone growths) have formed along the edges of the joints, having different shapes (straight, wavy, with a short or long base).

The fourth stage is also characterized by subchondral osteosclerosis and ankylosis of the joints. A sign of the first is the presence of bone compaction under the articular cartilage, and the second is a fusion of the joint, causing its complete immobility.

The pain in the joints no longer stops. At this stage, the patient may lose the ability to independently care for himself and become disabled.

There are 3 main factors as the cause of the disease (rheumatological triad)

Genetic predisposition
More common in carriers of a certain MHC II class antigen: HLA - DR1, DR4
Infectious factor
hepatoviruses - hepatitis B virus
herpes viruses - herpes simplex viruses, herpes zoster, Cytomegalovirus, Epstein-Barr virus
retroviruses - T-lymphotropic virus
Triggering factor (hypothermia, hyperinsolation, intoxication, mutagenic medications, endocrinopathies, stress, etc.). For women, breastfeeding for a longer period of time reduces the likelihood of developing RA. Breastfeeding for 24 months or longer reduces the risk of developing RA by half.

Are the radiological signs of RA different from other types of arthritis?

Using an x-ray, the doctor is able to make a differential diagnosis between different types of inflammatory joint disease. For example, with gouty arthritis, urate crystals (accumulations of uric acid) are visualized on x-rays.

The places where crystals are localized are periarticular tissues and joint space.

At the end parts of the epiphyses (edge of the tubular bone), one can notice the presence of a sclerotic border, and in the cortical layers - cystic defects. The soft tissues along the affected joints are enlarged, and the joint space is widened.

Radiological signs of psoriatic arthritis are different. Osteoporosis, which is an integral companion of RA, in this case occurs only in mutilating forms of the disease. Psoriatic arthritis is accompanied by the appearance of erosions in the distal interphalangeal joints. Such lesions form in the marginal zones of the joints, and then spread to the center.

The tops of the terminal and middle phalanges are ground off, the articular surface is concave, resulting in the visual effect of a “cup and saucer” or “pencils in a glass.”

X-ray signs of glenohumeral periarthritis (inflammation of the soft tissues around the shoulder joint) are the presence of deposits of small calcium crystals (calculous bursitis), osteoporosis of the head of the humerus (this symptom is especially pronounced in the ankylosing form of the disease associated with fusion of the joint and, as a result, its complete immobility).

Alternative methods for diagnosing rheumatoid arthritis

If a classic radiograph did not allow the specialist to make a diagnosis and create a treatment program, computed tomography (CT) may be prescribed for clearer visualization of bone tissue. It is also based on the use of X-rays, but the images obtained during this procedure are not flat, but three-dimensional, layer-by-layer and more accurate. Therefore, even minimal changes in tissues are visible on them. However, CT is associated with greater radiation exposure to the patient's body.

To assess the degree of involvement of the soft tissues surrounding the affected joint in the pathological process, magnetic resonance imaging (MRI) is prescribed. It also allows, like CT, to obtain volumetric images, but involves exposing the patient to a magnetic field and radiofrequency pulses. It is known that X-rays tend to accumulate well in bone tissue and pass through soft tissue without hindrance. Therefore, if the nature of the changes in the latter is poorly visible on x-rays, then MRI displays them in the most complete volume.

Ultrasound examination (US) is more sensitive to detecting erosions in joints, compared to radiography. It is also prescribed to those patients who cannot undergo X-rays, CT, or MRI, since ultrasound has no contraindications. Thus, it is impossible to say unequivocally which examination method for rheumatoid arthritis is the best. The choice of diagnostic method is made by the attending physician based on the symptoms with which the patient came to him.

Benefits of MRI for Arthritis

Complexity, that is, the ability to analyze the condition of both soft and bone tissues using magnetic waves during one examination.
Determines the pathological process at its early stage, which automatically increases the effectiveness of subsequent treatment measures and avoids disability as a result of uncontrolled progression of arthritis.
A detailed, detailed picture of the affected joint, including an image of all articular surfaces: the joint capsule, cartilage and parts of the ligamentous apparatus.
The ability to enlarge images several times, as well as view the resulting images from different angles in 3D format.
Control over the treatment process. Since arthritis can be examined on MRI an infinite number of times without any threat to health, using this method it is easy to monitor the effectiveness of treatment by obtaining comparative MRI images of the same joint before the start of the treatment process and throughout its entire duration.
Health safety and no radiation exposure.
Possibility of diagnostics in the presence of sutures and surgical staples, patients after heart surgery, with vena cava filters implanted in the inferior vena cava, as well as patients with artificial joints, disconnected medical pumps and shunts for hydrocephalus.

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Detailed x-ray description of the hands at different stages of rheumatoid arthritis.

There are 4 radiological stages of rheumatoid arthritis.

An example of a description of radiographs of the hands:

1st stage. An X-ray of the hands in a direct projection shows deformation of the proximal interphalangeal joints of the 2-3 fingers in the form of moderate thickening. Regional (periarticular) osteoporosis of the phalanges of the fingers of both hands is noted, the compact layer of the phalanges is moderately thinned.

2nd (A) stage. An X-ray of the hands in a direct projection shows deformation of the proximal interphalangeal joints of the 2-4 fingers due to thickening of the para-articular tissues. Regional periarticular osteoporosis of the phalanges of the fingers of both hands is noted, the compact layer of the phalanges is thinned. In the head of the middle phalanx of the 2nd finger there is a cyst-like lucency and a moderate narrowing of the joint space of the proximal interphalangeal joint of the same finger.

2nd (B) stage. An X-ray of the hands in a direct projection shows deformation of the proximal interphalangeal joints of the 1st-5th fingers due to thickening of the paraarticular tissues. There is pronounced regional periarticular osteoporosis of the phalanges of the fingers of both hands, the compact layer of the phalanges is thinned. In the heads of the middle phalanges of the 2nd to 4th fingers there is a cystic subchondral restructuring and narrowing of the joint space of the proximal interphalangeal joints of the 2nd to 5th fingers. In the heads of the middle phalanx of 2-3 fingers, marginal erosions measuring 2-2.5 mm in diameter with clear contours are detected (symmetrical changes).

3rd stage. An X-ray of the hands in a direct projection shows deformation of the proximal interphalangeal joints of the 2-5 fingers due to significant thickening of the paraarticular tissues, narrowing of the joint spaces and deformation of the subchondral plates of the interphalangeal joints. There is pronounced regional periarticular osteoporosis of the phalanges of the fingers of both hands, the compact layer of the phalanges is thinned. In the heads of the middle phalanges of the fingers there are multiple cyst-like lucencies and marginal usurations. Multiple ulnar subluxations of the metacarpophalangeal joints (ulnar deviation) are detected.

4th stage. An X-ray of the hands in a direct projection shows a pronounced deformation of the interphalangeal and metacarpophalangeal joints of the hand, the joint spaces are deformed and sharply narrowed with the presence of multiple subchondral cysts and marginal metaphyseal erosions. Severe widespread osteoporosis is noted. Severe, multiple ulnar subluxations of the metacarpophalangeal joints (ulnar deviation), partial osteolysis of the heads of the 2-5 main phalanges and 3-4 metacarpal bones, ankylosis of the 2nd metacarpophalangeal joint (symmetrical changes) are detected.

According to the classification, rheumatoid arthritis belongs to the group of autoimmune pathologies with a chronic course, which develops when a person’s immune status is weakened. The exact reasons why this pathology develops have not been identified to this day.

Predisposing factors include genetic predisposition, previous infectious processes (measles, mumps, hepatitis B), the effect of toxic substances on the human body, menopause and other autoimmune pathologies.

With the active progression of RA, symmetrical damage to the joints of the legs and arms (elbows, shoulders, hips, knees, hands and feet) develops. Small joint structures located on the upper extremities are usually affected first. First, the synovial membrane is involved in the inflammatory process, then this process affects the cartilage tissue, and as a result, the formation of erosions and irreversible deformation of the joints.

Arthritis can affect more than just joint elements. There are examples when it involves other organs and systems in the process. And the following changes begin to develop in the body: atrophy of the skeletal muscles, enlarged lymph nodes, the liver does not fully perform its functions, the gastrointestinal tract, lung tissue and heart muscle are affected, and possible damage to the skin.

Classification

According to ICD-10, the disease is systematized into the following groups:

1. Seropositive RA:

Felty's syndrome.
RA with involvement of other organs and systems.
Unspecified forms.

2. Youth RA.

3. Other RAs:

Seronegative type.
Still's disease.
Rheumatoid bursitis.
Rheumatoid nodule.
Other specified and unspecified arthritis.

According to clinical manifestations, the disease is divided into the primary stage (less than 6 months have passed since the onset of the disease), early (from 6 months to a year), advanced (from 1 year) and late (more than 2 years). Rheumatoid arthritis is distinguished by the degree of loss of functionality, immunological factors, disease activity, and instrumental characteristics.

For doctors, immunological characteristics are of greatest importance. The presence of rheumatoid factor in the blood or the presence of anti-CCP (seropositive and seronegative RA). The results of tests that reveal these values allow you to correctly plan therapy.

X-ray stages of rheumatoid arthritis

With the help of X-ray examination, it is possible to determine the level of joint damage and deformation of bone structures, and of course cartilage and soft periarticular tissues. When determining the stage of RA, special attention is paid to the most affected joint, and the number of erosions formed in the bone tissue is calculated.

These manifestations make it possible to determine the stage of rheumatoid arthritis for a particular patient individually, since for each victim the degree of joint destruction and the number of erosions formed may be different.

It is very important to determine the presence of pathological formations such as erosions and cyst-like clearings during an x-ray. Unfortunately, they are almost impossible to notice using X-rays, since they are small in size and the equipment has poor clarity.

To establish the correct diagnosis in the initial stages, magnetic resonance or computed tomography is additionally used to study in detail the degenerative processes in the joints.

Based on X-ray images, four stages of rheumatoid arthritis can be distinguished.

Stage I

The first stage or initial. At the initial level, the joints of the hands and metatarsophalangeal joints undergo degenerative changes.

In the photo you can see thickening and compaction of the periarticular soft tissues, bone damage. Namely, their thinning and the presence of small cyst-like clearings in them.

You can very clearly see periarticular osteoporosis, which is characterized by degenerative modifications in bone tissue. Bone structures become looser, their porosity increases, which leads to their fragility.

An experienced specialist may notice a narrowing of the joint space in the image, which is a characteristic sign of disease progression.

This stage is characterized by morning stiffness of the joints, which goes away on its own within 1 hour after waking up. The affected area is slightly swollen, and during minor physical activity or heavy lifting the patient experiences unpleasant but tolerable pain.

These are the main external indicators of the development of pathology, and if they occur, you should consult a rheumatologist.

Primary manifestations of rheumatoid arthritis can develop at any age. They can be either in a small patient or in a fairly adult person. And the disease can progress in different ways: rapid development may occur immediately after the initial signs, or there may be a lull for several years.

Stage II

During the active progression of the second stage of rheumatoid arthritis, numerous cysts form in the bone structures, periarticular osteoporosis gains momentum and the lumen of the joint space narrows in one or several joints at once - these are characteristic signs of stage 2A. Stage 2A lasts until bone erosions begin to form.

Erosive formations can be divided into three groups:

Marginal superficial erosions most often form on small joints of the upper extremities. Erosion forms where the joint is not covered with cartilage tissue, namely its intra-articular area.
Due to progressive periarticular osteoporosis, a gap is formed on the surface of the bone, which is characteristic of compression-type erosions.
The third type of erosion formations includes superficial degradation of the bone tissue of the endplate at the site of attachment of the joint with ligaments.

Formations are the primary diagnostic feature of the formation of rheumatoid arthritis. As soon as the X-ray image shows the formation of erosive structures, we can begin to describe the next stage - 2B, which continues until four erosions are formed.

At this stage, mobility may be lost for 2-3 hours a day, this is due to the destruction of cartilage tissue. During physical activity, the patient's pain increases.

Stage III

After five erosive formations have formed, we can move on to discussing the third stage of RA. Atrophic changes in the muscle tissue surrounding the joint develop.

Compression of joint spaces, multiple formed cysts and progressive periarticular osteoporosis are accompanied by dislocations with deformation of the hands.

These deformations have different names. The most common hand modifications include “walrus fins,” “swan necks,” and “button loops.”

Using an x-ray, you can see the formation of calcifications near the affected area. In their structure, calcifications resemble rheumatoid nodules, which grow in diameter up to 2–3 cm.

Due to the oversaturation of the body with calcium salts, calcifications begin to form. In their structure, rheumatoid nodules are quite dense, have a round shape, and are painless during palpation.

Calcifications are very clearly visible on x-ray images.

Pain and limited movement limit a person to such an extent that he cannot perform the simplest daily activities. And physical exercise or training becomes impossible and is excluded from the patient’s daily routine.

IV stage

At this stage, periarticular osteoporosis begins to progress rapidly.

Erosive formations begin to affect not only the surface of the joints, but also nearby bone structures. Osteophytes begin to form at the edges of the joint surfaces as an addition to the compression of the joint spaces.
Osteophytes in their structure are bone formations that form only at the edges of the articular surfaces. They are irrefutable signs of the development of rheumatoid arthritis. At the first stages of their formation, they have a pointed shape and resemble small bone growths.
As the disease progresses, the volume of osteophytes increases, as well as their shape; they can be wavy or straight, as well as on a short or long base.

Various cyst-like clearings, dislocations and subluxations of joints, as well as deformed bone tissue are accompanied by ankylosis of the joints and subchondral osteosclerosis.

An X-ray image can reveal a bone formation under the cartilage - this is subchondral osteosclerosis. This pathology is formed when the joint space is severely narrowed. Due to progressive deformation of the cartilage or its complete absence, a process of friction occurs between the exposed bones of the joints.

Ankylosis is the complete immobilization of a joint due to irreversible deformation processes that occurred as a result of the progress of rheumatoid arthritis. At this stage, the patient develops almost complete immobilization and severe, incessant pain.