What is the diagnosis and treatment for hand pain with mild degenerative changes and no fracture?

Hand Osteoarthritis: Diagnosis and Treatment

The radiographic findings described indicate hand osteoarthritis (HOA) primarily affecting the first carpometacarpal (CMC), first metacarpophalangeal (MCP), first interphalangeal (IP), and second distal interphalangeal (DIP) joints, which should be treated with a combination of non-pharmacological and pharmacological approaches starting with education, exercise, and acetaminophen. 1

Diagnosis

The radiographic findings clearly support a diagnosis of hand osteoarthritis with the following key features:

• No fracture with anatomic alignment of bones
• Mild scattered periarticular degenerative changes
• Most significant involvement of first CMC, first MCP, first IP, and second DIP joints
• Tiny marginal osteophytes
• Subtle subchondral/subcortical cysts
• No osseous erosions
• No focal soft tissue abnormality

This presentation is consistent with typical hand osteoarthritis, which commonly affects the DIP, PIP, and thumb base joints 1. The distribution pattern showing involvement of characteristic target joints with osteophytes and subchondral cysts is diagnostic for HOA in adults over 40 years of age.

Imaging Considerations

Standard radiographs (posteroanterior, lateral, and oblique views) are the gold standard for morphological assessment of HOA 1, 2. In this case, the radiographs have provided sufficient information for diagnosis, showing the classic features of joint space narrowing, osteophytes, and subchondral bone sclerosis.

Additional imaging is generally not required for diagnosis, as:

• MRI without IV contrast is of limited benefit in nonspecific pain and shows no difference in assessment of joint space narrowing, bone erosion, and malalignment compared with radiographs 1
• Ultrasound may be considered if there's suspicion of synovitis, joint effusion, or tendon pathology 1
• CT, MR arthrography, and bone scans are not supported by evidence for routine use in HOA 1

Treatment Algorithm

1. Non-pharmacological Approaches (First-line)

• Education and Joint Protection: Teach patients how to avoid adverse mechanical factors 1
• Exercise Regimen: Implement both range of motion and strengthening exercises 1
• Heat Application: Local application of heat (paraffin wax, hot packs) especially before exercise 1
• Splints/Orthoses: Particularly for thumb base OA to prevent/correct deformities 1

2. Pharmacological Management (Stepwise Approach)

• First-line: Topical treatments for mild to moderate pain affecting few joints

  • Topical NSAIDs
  • Topical capsaicin

• Second-line: Oral medications

  • Acetaminophen (up to 4g/day) as first-choice oral analgesic due to efficacy and safety profile 1
  • If inadequate response to acetaminophen, proceed to oral NSAIDs at lowest effective dose for shortest duration 1
    • For patients with increased GI risk: non-selective NSAIDs plus gastroprotective agent or selective COX-2 inhibitor
    • For patients with increased CV risk: avoid COX-2 inhibitors; use non-selective NSAIDs with caution

• Third-line: Consider symptomatic slow-acting drugs for osteoarthritis (SYSADOAs)

  • Options include glucosamine, chondroitin sulfate, avocado soybean unsaponifiables, diacerhein
  • Note: Effect sizes are small and suitable patients are not well-defined 1

• Fourth-line: For painful flares, especially in thumb CMC joint

  • Intra-articular corticosteroid injections 1

3. Advanced Interventions

• Surgery: Consider for severe thumb base OA with marked pain/disability when conservative treatments have failed 1
  • Options include interposition arthroplasty, osteotomy, or arthrodesis

Emerging Treatments

Recent research has explored additional options:

• Transdermal CBD gel has shown promise in reducing pain and improving grip strength in HOA in an open-label feasibility trial 3
• Low-dose radiation therapy has demonstrated symptomatic relief in HOA patients 4

Important Clinical Considerations

1. Functional Impact: Hand OA may cause functional impairment as severe as rheumatoid arthritis and should be carefully assessed 1

2. Correlation with Symptoms: Clinical assessments of hand function may not correlate strongly with radiographic findings 5, emphasizing the importance of treating the patient's symptoms rather than the radiographic appearance

3. Associated Conditions: Patients with polyarticular HOA are at increased risk of knee OA, hip OA, and generalized OA 1

4. Treatment Individualization: While following the algorithm above, consider factors such as:

   • Location of OA
   • Presence of inflammation
   • Severity of structural change
   • Level of pain and disability
   • Comorbidities and co-medications 1

5. Regular Reassessment: The disease course often changes over time, requiring periodic review and adjustment of therapy rather than rigid continuation of a single treatment 6