What is the next step in managing degenerative changes in the left hand, specifically in the DIP (distal interphalangeal) joint, carpometacarpal joint of the thumb, and intercarpal joints?

From the Guidelines

The next step in managing degenerative changes in the left hand, specifically in the DIP joint, carpometacarpal joint of the thumb, and intercarpal joints, should begin with conservative treatment, as recommended by the 2019 American College of Rheumatology guideline for the management of osteoarthritis of the hand, hip, and knee 1.

Conservative Treatment Approach

The treatment approach should include:

• Oral NSAIDs, such as ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily), for 2-3 weeks to reduce inflammation and pain
• Physical therapy focusing on hand strengthening exercises and range of motion activities, performed daily for 15-20 minutes
• Splinting the affected joints, particularly at night or during activities that exacerbate pain, to provide additional relief
• Topical NSAIDs, like diclofenac gel (1% applied to affected joints four times daily), to supplement oral medication with fewer systemic side effects

Rationale for Conservative Treatment

This approach is recommended because it addresses inflammation and pain while preserving joint function, before considering more invasive surgical options like joint fusion or arthroplasty, which would only be indicated if conservative management fails, as supported by the EULAR evidence-based recommendations for the management of hand osteoarthritis 1.

Additional Considerations

If these measures prove insufficient after 4-6 weeks, consider corticosteroid injections (typically methylprednisolone 20-40mg or triamcinolone 10-40mg mixed with lidocaine) into the affected joints, which may provide relief for several months, as conditionally recommended by the American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee 1.

From the Research

Next Steps in Managing Degenerative Changes

The next steps in managing degenerative changes in the left hand, specifically in the DIP joint, carpometacarpal joint of the thumb, and intercarpal joints, may involve a combination of conservative and surgical measures.

• Conservative measures may include:
  • Oral anti-inflammatory medications 2
  • Activity modification and splinting 2
  • Intraarticular corticosteroid injections 2, 3
  • Physical therapy 4
• Surgical interventions may be considered for more advanced cases, such as:
  • Arthroscopic synovectomy 2
  • Arthroplasty 2
  • Arthrodesis of the affected articulations 2

Considerations for Specific Joints

• For the carpometacarpal joint of the thumb, early treatment options may include nonoperative or less invasive surgical techniques to relieve symptoms, restore function and strength, and stop the progression of the disease 5.
• For the DIP joint, treatment options may be similar to those for the thumb metacarpophalangeal and interphalangeal joints, including conservative measures and surgical interventions such as arthrodesis 2.
• For the intercarpal joints, treatment options may be similar to those for other joints affected by degenerative changes, including conservative measures and surgical interventions 2, 4.

Important Considerations

• The choice of treatment will depend on the severity of symptoms, the degree of joint degeneration, and the patient's overall health and lifestyle 2, 5, 4.
• It is essential to weigh the potential benefits and risks of each treatment option, including the potential side effects of oral and intra-articular medications 3.