Osteoarthritis of the hand
In osteoarthritis of the hand, the most commonly affected joints are the distal interphalangeal joints and the first (thumb) carpometacarpal joints. Affected distal interphalangeal joints may go through a painful inflammatory phase, lasting from a few months to a few years, which then settles leaving residual bony deformity (Heberden nodes) that does not significantly impact physical function. Primary generalised nodal osteoarthritis is a subtype of osteoarthritis that can involve multiple distal and proximal interphalangeal joints and significantly impact physical function. Thumb-based carpometacarpal osteoarthritis can occur in isolation or as part of primary generalised nodal osteoarthritis. It usually has a significant impact on physical function.
Relatively few randomised controlled trials have been conducted for osteoarthritis of the hand; however, there is evidence that nonsurgical (nonpharmacological and pharmacological) management can prevent the need for surgery. For initial management, the following interventions may be beneficial:
- strategies to minimise symptoms when performing activities of daily living (often referred to as joint protection techniques)
- assistive devices as needed for performing activities of daily living (eg tap turner), based on an assessment of the patient’s abilities
- splints for thumb-based carpometacarpal osteoarthritis—for information see the HANDI (Handbook of Non-Drug Interventions) website
- strengthening and stretching hand exercises
- application of heat.
If needed, the above interventions can be combined with topical or oral analgesia. Topical treatments are preferred, and topical NSAIDs are the first topical treatment of choice. Opioids are not recommended for osteoarthritis of the hand.
[NB1]
- Distribute the weight of lifted objects over several joints (eg spread the load over 2 hands).
- Avoid repetitive thumb movements and putting strain on the thumb.
- Avoid a prolonged grip in one position.
- Use as large a grip as possible.
- Reduce the effort needed to do a task (eg use labour-saving gadgets, avoid lifting heavy objects, reduce the weight of what is lifted).
- Conserve energy by planning activities (eg organise tasks more efficiently) and pacing them (eg take regular short breaks).
NB1: More information on these strategies can be found on the HANDI (Handbook of Non-Drug Interventions) website
Source: Dziedzic K, Nicholls E, Hill S, Hammond A, Handy J, Thomas E, et al. Self-management approaches for osteoarthritis in the hand: a 2x2 factorial randomised trial. Ann Rheum Dis 2015;74(1):108-18. https://www.ncbi.nlm.nih.gov/pubmed/24107979
.Intramuscular corticosteroids can reduce inflammation and improve symptoms in patients with primary generalised nodal osteoarthritis; however, their use is currently not recommended because of the lack of long-term effectiveness data and the potential for long-term adverse effects.
Evidence suggests intra-articular corticosteroid injections and intra-articular hyaluronan injections are not more effective than placebo for carpometacarpal osteoarthritis, including thumb-based carpometacarpal osteoarthritis. The suggested benefit of intra-articular corticosteroids in interphalangeal osteoarthritis requires confirmation.
There is insufficient evidence to recommend hydroxychloroquine, methotrexate or sulfasalazine for osteoarthritis of the hand, although they are sometimes considered for inflammatory and erosive osteoarthritis. These drugs should only be started in consultation with a rheumatologist.
A single trial suggests chondroitin sulfate may be of benefit in hand osteoarthritis for pain relief and improving function1Gabay, 2011.
Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain. Trapeziectomy should be considered in patients with thumb-base osteoarthritis, and arthrodesis or arthroplasty in patients with interphalangeal osteoarthritis.