From the Guidelines
For a 49-year-old male with posttraumatic and degenerative arthritic changes in the wrist, the recommended treatment should prioritize conservative measures, including education on joint protection, exercise regimen, and local treatments, before considering surgical options, as suggested by the most recent and highest quality study 1.
Initial Management
- Oral paracetamol (up to 4g/day) is the preferred initial analgesic, due to its efficacy and safety, as recommended by 1 and supported by older studies such as 1.
- Topical NSAIDs and capsaicin are effective and safe treatments for hand OA, as indicated by 1.
- Local application of heat and ultrasound may also be beneficial, although the evidence for ultrasound is weaker, as noted in 1.
Supportive Measures
- A wrist splint may be recommended to prevent or correct lateral angulation and flexion deformity, especially for thumb base OA, as suggested by 1.
- Physical therapy focusing on range-of-motion exercises, strengthening, and joint protection techniques can be beneficial, as implied by the general principles of managing OA in 1.
Invasive Options
- Intra-articular injection of long-acting corticosteroid may be effective for painful flares, especially in the trapeziometacarpal joint OA, as indicated by 1.
- Surgery, such as interposition arthroplasty, osteotomy, or arthrodesis, is considered for severe cases with marked pain and/or disability when conservative treatments have failed, as recommended by 1.
Considerations
- The treatment should be individualized according to the patient's specific condition, including localization of OA, risk factors, type of OA, presence of inflammation, severity of structural change, level of pain, disability, and restriction of quality of life, as emphasized by 1.
- The patient's wishes and expectations should also be taken into account, as suggested by 1. Given the most recent evidence from 1 regarding chronic hand and wrist pain, which suggests radiography as the initial imaging study and reserves further imaging like MR arthrography or MRI without IV contrast for when initial studies are normal or nonspecific, the approach should be conservative and stepped, with a focus on managing symptoms and preserving function, before considering more invasive diagnostic or therapeutic interventions.
From the Research
Treatment Options for Posttraumatic and Degenerative Arthritis
The patient's condition, characterized by posttraumatic and degenerative arthritic changes in the wrist, requires a comprehensive treatment approach.
- First-Line Therapy: According to international recommendations 2, 3, acetaminophen should be considered as the first-line therapy due to its safety and effectiveness.
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): If the patient is unresponsive to acetaminophen, NSAIDs can be considered 2, 3. However, they should be prescribed at the lowest effective dose and for the shortest duration.
- Symptomatic Slow Acting Drugs: Drugs such as avocado soybean unsaponifiable, chondroitin sulphate, diacerein, and glucosamine sulphate have mild symptomatic effects and may reduce the consumption of NSAIDs 2, 3.
- Gastrointestinal Protection: The addition of a proton pump inhibitor to NSAID therapy can reduce the risk of peptic ulcer bleeding by ≥80% 4.
- Alternative Options: In cases where NSAIDs are contraindicated or ineffective, alternative options such as weak opioids and narcotic analgesics may be considered 2, 3.
Considerations for Treatment
When selecting a treatment option, it is essential to consider the patient's medical history, current medications, and potential contraindications.
- Cardiovascular Disease: Patients with a history of cardiovascular disease, such as myocardial infarctions, should be cautious when using NSAIDs 4.
- Gastrointestinal Risks: Patients with a history of gastrointestinal disease or bleeding should be monitored closely when using NSAIDs 5, 4.
- Dosage and Duration: The dosage and duration of treatment should be carefully considered to minimize the risk of adverse effects 2, 3.