European Journal of Cardiovascular Medicine

Arthritis is a leading cause of chronic pain, disability, and joint deformity worldwide, particularly involving the small joints of the hands and wrists, which play a vital role in daily functioning. Early identification of synovial inflammation and structural joint damage is essential to initiate disease-modifying therapy and prevent irreversible disability. Imaging modalities are indispensable in this context, offering both diagnostic and prognostic insights into disease activity and progression.

Plain radiography has long been the traditional imaging technique due to its wide availability and ability to depict bony erosions, joint space narrowing, and osteophyte formation. However, these radiographic findings typically represent late-stage disease. Early inflammatory changes such as synovial hypertrophy or effusion often remain undetected, limiting the sensitivity of radiography in early arthritis [1,2].

In contrast, high-resolution ultrasonography (USG) provides superior visualization of soft tissue and synovial pathology, enabling earlier diagnosis. USG allows dynamic, real-time evaluation of synovial thickening, effusion, tenosynovitis, and power Doppler vascularity, which directly correlate with inflammatory activity and disease progression [3,4]. The addition of Power Doppler ultrasonography (PDUS) has further enhanced its diagnostic potential by identifying active synovial perfusion, a surrogate marker of inflammation [4,5].

Several studies have demonstrated that USG can reveal subclinical synovitis even in joints with normal radiographs, underscoring its role in early diagnosis and monitoring of treatment response [1,3,5]. Moreover, ultrasonography is a non-invasive, radiation-free, and cost-effective modality suitable for serial follow-up, thereby complementing radiography rather than replacing it.

The present study was designed to systematically compare the diagnostic performance of ultrasonography and plain radiography in patients presenting with arthritis of the small joints of the hands. It further aimed to correlate imaging findings with clinical and serological markers of inflammation, thereby delineating the complementary roles of both modalities in comprehensive arthritis evaluation

Study Design and Setting

A prospective observational study was conducted in the Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences (AIIMS), Bhopal, over a defined study period. Ethical approval was obtained from the Institutional Ethics Committee prior to initiation, and written informed consent was secured from all participants in accordance with the Declaration of Helsinki.

Study Population

A total of 100 patients presenting to the outpatient and inpatient departments with clinical evidence of arthritis involving the small joints of the hands and wrists were enrolled consecutively. Both male and female adults aged above 18 years were included.

Inclusion Criteria

Patients with clinical suspicion or diagnosis of rheumatoid arthritis, osteoarthritis, psoriatic arthritis, or gouty arthritis.

Willingness to provide informed consent and undergo imaging evaluation.

Exclusion Criteria

History of traumatic or post-surgical deformity of the hand or wrist.

Patients with secondary causes of arthritis such as septic arthritis, metabolic bone disease, or malignancy.

Individuals unable to cooperate during imaging or with contraindications to radiographic exposure.

Imaging Protocols

1. Plain Radiography:
   Standard anteroposterior (AP) and lateral views of both hands and wrists were obtained using a digital radiography unit with standardized exposure parameters (kVp = 2.5–4.5; mAs = 40–50). Each film was evaluated for:

Periarticular soft tissue swelling

Juxta-articular osteopenia

Joint space narrowing

Marginal erosions

Osteophytes

Subluxations and deformities

2. Ultrasonography (USG):
   All patients underwent high-resolution ultrasound using a linear transducer (10–15 MHz) on a GE or Philips system. Both dorsal and palmar aspects of each hand and wrist were scanned in longitudinal and transverse planes. Grey-scale and Power Doppler techniques were used to assess:

Synovial hypertrophy (graded I–IV based on Szkudlarek’s criteria)

Joint effusion (graded I–IV depending on capsular distension)

Synovial hyperemia (graded I–IV as per Stone’s Doppler activity scale)

Tenosynovitis, erosions, and osteophytes

Laboratory Correlation

Inflammatory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and rheumatoid factor (RF) were analyzed for all patients. Correlations were drawn between these parameters and ultrasonographic as well as radiographic findings.

Data Collection and Analysis

All observations were systematically recorded in a pre-structured proforma. Data were entered into Microsoft Excel and analyzed using SPSS version 22.0. Categorical variables were expressed as frequencies and percentages, while continuous variables were summarized as mean ± SD. Associations between USG and X-ray findings and between imaging and serological markers were evaluated using the Chi-square test and Pearson correlation, with p < 0.05 considered statistically significant.

Outcome Measures

The primary outcome was to determine the diagnostic concordance between ultrasonography and radiography in evaluating small joint arthritis. Secondary outcomes included identifying correlations of imaging findings with ESR, CRP, and RF levels, thereby determining the sensitivity of each modality in early inflammatory detections.

A total of 100 patients presenting with clinical evidence of small joint arthritis of the hands and wrists were evaluated using both ultrasonography (USG) and plain radiography.

Demographic and Clinical Profile

The baseline characteristics of the study population are summarized in Table 1. The majority of patients (46%) belonged to the 41–60 years age group, followed by 20–40 years (32%) and above 60 years (22%). Females predominated (62%) over males (38%), reflecting the higher prevalence of inflammatory arthropathies among women. Bilateral joint involvement was observed in 84% of cases, while unilateral presentation accounted for 16%. Symptom duration ranged from less than 6 months to over a year, with 52% of patients reporting a duration of 6–12 months.

Table 1. Baseline Demographic and Clinical Characteristics (n = 100)

Distribution of Diagnosed Arthritic Conditions

As shown in Table 2, rheumatoid arthritis (RA) constituted the largest diagnostic category (48%), followed by osteoarthritis (26%), psoriatic arthritis (16%), and gouty arthritis (10%). The predominance of rheumatoid arthritis underscores its clinical and radiological significance in small joint pathology of the hands and wrists.

Table 2. Distribution of Diagnosed Arthritic Conditions

Figure 1: Distribution of Diagnosed Arthritic Conditions

Correlation Between Ultrasonography and Radiographic Findings

Comparative analysis between USG and X-ray findings revealed a strong degree of diagnostic concordance (Table 3). Ultrasonography detected a higher number of positive findings across all parameters, particularly for joint effusion (65 vs. 52) and synovial hypertrophy (60 vs. 48). The agreement between the two modalities exceeded 80% for most features, with statistically significant correlations (p < 0.05).

Osteophyte detection showed the highest concordance (90%), followed by joint space narrowing (90.7%) and erosions (82.6%). Power Doppler evaluation revealed hyperemia in 58 patients, compared to radiographic correlates in 44, emphasizing the superior sensitivity of USG in identifying early inflammatory activity.

Table 3. Correlation between Ultrasound (USG) and X-ray Findings

Association of Inflammatory Markers with Imaging Findings in RA

Among the 48 patients diagnosed with rheumatoid arthritis, inflammatory markers such as ESR, CRP, and rheumatoid factor demonstrated a consistent association with both ultrasonographic and radiographic abnormalities (Table 4). Elevated ESR was found in 83% of RA patients, and 90% of them exhibited synovial hypertrophy on USG. Similarly, CRP positivity correlated with hyperemia (80%) and erosions (74.3%). The presence of rheumatoid factor paralleled significant imaging findings, notably synovial hypertrophy (86.8%) and joint space narrowing (73.6%). These associations reinforce the utility of combining serological and imaging modalities for comprehensive disease evaluation.

Table 4. Association of Inflammatory Markers with USG and X-ray Findings in RA Patients (n = 48)

Grading of Ultrasonographic Abnormalities in Rheumatoid Arthritis

The distribution of ultrasonographic grades for synovial hypertrophy, hyperemia, and joint effusion is presented in Table 5. Grade III changes were the most prevalent, observed in 37.5% of patients for synovial hypertrophy and 41.7% for hyperemia, indicating active inflammatory disease. Joint effusion of Grade III severity was documented in 45.8% of cases. Only 16.6% of patients exhibited Grade IV changes, consistent with advanced disease or longstanding synovitis.

Table 5. Severity Grading of USG Parameters in Rheumatoid Arthritis

The present prospective study compared ultrasonography (USG) and radiography in the evaluation of small joint arthritis of the hands and wrists, emphasizing their diagnostic correlation with inflammatory markers. The results demonstrated that USG identified early inflammatory changes with greater sensitivity, whereas radiography remained essential for chronic structural assessment.

Diagnostic Performance of Ultrasonography and Radiography

Ultrasonography detected more abnormalities across all parameters—particularly joint effusion (65 vs. 52) and synovial hypertrophy (60 vs. 48)—with strong statistical concordance (p < 0.001). These findings confirm the superior diagnostic yield of USG for soft-tissue pathology. Comparable outcomes were observed by Sivakumaran et al. [6], who highlighted that ultrasound surpasses conventional radiography in identifying early osteoarthritic changes in small hand joints. Similarly, Jindal et al. [12] found that ultrasonography demonstrated higher sensitivity in detecting synovitis and early erosions in rheumatoid arthritis compared to X-ray, especially during the initial disease phase.

Power Doppler and Inflammatory Activity

Power Doppler ultrasonography revealed hyperemia in 58% of cases, strongly correlating with elevated ESR and CRP values. This indicates that PDUS is a valuable marker of synovial vascularity and active inflammation. The study by Koski et al. [7] established a direct association between Doppler signal intensity and histopathological vascular proliferation in synovial tissue. Likewise, Scheel et al. [8] validated semi-quantitative grading systems for evaluating Doppler activity, reinforcing its role as a sensitive measure of inflammatory burden.

Correlation with Laboratory Parameters

The present findings demonstrated robust associations between ESR, CRP, and USG parameters—notably synovial hypertrophy and vascularity—consistent with prior observations by Andersen et al. [11], who confirmed that Doppler activity corresponds closely to synovial pathology in biopsy samples from rheumatoid joints. Elevated inflammatory markers thus reflect the degree of active synovitis visualized on ultrasonography, supporting its integration with serological indices in disease monitoring.

Relevance to Recent Literature

Recent research continues to affirm the diagnostic utility of USG over radiography. De Agustín de Oro et al. [9] underscored that ultrasound not only detects early inflammatory lesions but also quantifies synovial thickening and perfusion with precision, aiding treatment decisions. Similarly, Backhaus et al. [10] demonstrated that a focused 7-joint ultrasound score reliably assesses inflammation in daily rheumatologic practice, offering a reproducible framework for clinical application.

Clinical Implications

The present results corroborate that ultrasonography provides an enhanced, real-time depiction of inflammatory activity, while radiography serves as a confirmatory tool for osseous deformities and chronic progression. Combined interpretation allows comprehensive evaluation—from active synovitis to established structural damage—improving diagnostic accuracy and therapeutic monitoring.

Strengths and Limitations

This study’s strengths include its prospective design, uniform imaging protocol, and correlation of imaging with serological data. Limitations include its single-center nature, limited sample size, and absence of longitudinal follow-up to assess treatment response or radiographic progression.

The present study establishes that ultrasonography surpasses plain radiography in detecting early inflammatory changes in small joint arthritis of the hands and wrists. Ultrasonography, particularly with Power Doppler, accurately identifies synovial hypertrophy, effusion, and hyperemia even before structural deformities appear radiographically. Radiography, however, remains indispensable for evaluating chronic bony alterations such as erosions and osteophytes. The significant correlation between ultrasonographic findings and inflammatory markers (ESR, CRP, RF) highlights its clinical relevance in disease monitoring. Together, both modalities provide a complementary diagnostic framework radiography defining chronicity and ultrasonography delineating current inflammatory activity thereby optimizing diagnosis, prognosis, and management in arthritic disorders.

1. Keen HI, Wakefield RJ, Grainger AJ, Hensor EM, Emery P, Conaghan PG. Can ultrasonography improve on radiographic assessment in osteoarthritis of the hands? A comparison between radiographic and ultrasonographic detected pathology. Ann Rheum Dis. 2008 Aug;67(8):1116-20. doi: 10.1136/ard.2007.079483. Epub 2007 Nov 23. PMID: 18037626.
2. Wakefield RJ, Gibbon WW, Conaghan PG, O'Connor P, McGonagle D, Pease C, Green MJ, Veale DJ, Isaacs JD, Emery P. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum. 2000 Dec;43(12):2762-70. doi: 10.1002/1529-0131(200012)43:12<2762::AID-ANR16>3.0.CO;2-#. PMID: 11145034.
3. McNally EG. Ultrasound of the small joints of the hands and feet: current status. Skeletal Radiol. 2008 Feb;37(2):99-113. doi: 10.1007/s00256-007-0356-9. Epub 2007 Aug 22. PMID: 17712556; PMCID: PMC2141652.
4. Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M, Klausen T, Ostergaard M. Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging. Arthritis Rheum. 2001 Sep;44(9):2018-23. doi: 10.1002/1529-0131(200109)44:9<2018::AID-ART350>3.0.CO;2-C. PMID: 11592362.
5. Filippucci E, Iagnocco A, Salaffi F, Cerioni A, Valesini G, Grassi W. Power Doppler sonography monitoring of synovial perfusion at the wrist joints in patients with rheumatoid arthritis treated with adalimumab. Ann Rheum Dis. 2006 Nov;65(11):1433-7. doi: 10.1136/ard.2005.044628. Epub 2006 Feb 27. PMID: 16504996; PMCID: PMC1798349.
6. Sivakumaran P, Hussain S, Ciurtin C. Comparison between Several Ultrasound Hand Joint Scores and Conventional Radiography in Diagnosing Hand Osteoarthritis. Ultrasound Med Biol. 2018 Mar;44(3):544-550. doi: 10.1016/j.ultrasmedbio.2017.11.009. Epub 2017 Dec 27. PMID: 29289433.
7. Koski JM, Saarakkala S, Helle M, Hakulinen U, Heikkinen JO, Hermunen H. Power Doppler ultrasonography and synovitis: correlating ultrasound imaging with histopathological findings and evaluating the performance of ultrasound equipments. Ann Rheum Dis. 2006 Dec;65(12):1590-5. doi: 10.1136/ard.2005.051235. Epub 2006 May 17. PMID: 16707536; PMCID: PMC1798460.
8. Scheel AK, Hermann KG, Kahler E, Pasewaldt D, Fritz J, Hamm B, et al. A novel ultrasonographic synovitis scoring system suitable for analyzing finger joint inflammation in rheumatoid arthritis. Arthritis Rheum. 2005 Mar;52(3):733-43. doi: 10.1002/art.20939. PMID: 15751062.
9. de Agustin de Oro JJ, Soria LM, Fernandez AP, Segarra VT. Ultrasound in the evaluation of rheumatoid arthritis. Eur J Rheumatol. 2022 Apr 15;11(3):S277-S282. doi: 10.5152/eurjrheum.2022.20224. PMID: 35943461; PMCID: PMC11664843.
10. Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus TM, Hartung W, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum. 2009 Sep 15;61(9):1194-201. doi: 10.1002/art.24646. PMID: 19714611.
11. Andersen M, Ellegaard K, Hebsgaard JB, Christensen R, Torp-Pedersen S, Kvist PH, et al. Ultrasound colour Doppler is associated with synovial pathology in biopsies from hand joints in rheumatoid arthritis patients: a cross-sectional study. Ann Rheum Dis. 2014 Apr;73(4):678-83. doi: 10.1136/annrheumdis-2012-202669. Epub 2013 Mar 8. PMID: 23475981.
12. Jindal G, Bansal S, Gupta N, Singh SK, Gahukar S, Kumar A. Comparison of Ultrasonography and X-Rays for the Diagnosis of Synovitis and Bony Erosions in Small Joints of Hands in Early Rheumatoid Arthritis: a Prospective Study. Maedica (Bucur). 2021 Mar;16(1):22-28. doi: 10.26574/maedica.2020.16.1.22. PMID: 34221152; PMCID: PMC8224727.