June 2024
Are routine x-rays of hands and feet worthwhile in patients with suspected rheumatoid arthritis?

In a large study, the yield of this practice was extremely low.

Primary care clinicians and rheumatologists often obtain x-rays of hands and feet in patients with suspected rheumatoid arthritis (RA); the rationale is that finding erosions typical for RA will be useful diagnostically and prognostically. In a retrospective study, Dutch researchers examined the yield of this practice among 724 new patients evaluated for suspected RA at a university rheumatology clinic; all patients had routine x-rays of hands and feet. Median symptom duration was six months at the initial visit.

RA eventually was diagnosed in 41% of the 724 patients. Only 32 patients – 4% of the overall cohort – had erosions typical for RA on initial presentation. The prevalence of erosions was lower in seronegative patients and in patients without elevated acute phase reactants than in patients with these markers. Presence of erosions helped to establish diagnoses of RA in only two patients and helped reclassify only three patients into a poor-prognosis category (according to European treatment recommendations; Ann Rheum Dis 2023; 82: 3-18). Presence of erosions was not associated with patient-reported duration of symptoms.

Comment: For years, I’ve been unsure about whether routine hand x-rays are worthwhile in patients who present with symptoms suggestive of early RA. The findings in this study tip the balance against that practice. As an aside, ultrasonography – used increasingly by some rheumatologists for diagnosis and disease monitoring – is more sensitive than x-ray in detecting erosions in hand joints; however, it is unclear whether routine use of ultrasonography for early RA diagnosis ultimately would improve clinical outcomes.

Allan S. Brett, MD, Clinical Professor of Medicine, University of Colorado School of Medicine, Aurora, USA.

Ulijn E, et al. Limited diagnostic and prognostic value of routine radiographs in newly presenting arthritis suspected of rheumatoid arthritis: a retrospective study. Arthritis Care Res (Hoboken) 2024; 76: 497-502.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine.

Arthritis Care Res