What is the initial management for degenerative changes in the carpometacarpal (CMC) joint?

Initial Management for Degenerative Changes in the Carpometacarpal (CMC) Joint

The initial management for degenerative changes in the carpometacarpal joint should include orthosis (splinting), particularly with neoprene or rigid orthoses for the first CMC joint, combined with topical NSAIDs as first-line pharmacological treatment. 1, 2

Non-Pharmacological Management

Orthoses/Splinting

• First CMC joint orthoses: Strongly recommended as initial treatment 1, 2
  • Options include:
    • Neoprene orthoses - more flexible, better for daytime use
    • Rigid orthoses - better for nighttime use and more severe symptoms
  • Should be worn at night to provide rest and stability to the joint 2
  • Can be used for both short-term and long-term symptom relief 1

Exercise Therapy

• Active finger motion exercises to maintain mobility 2
• Range of motion exercises to prevent stiffness 2
• Strengthening exercises to stabilize the joint 2
• Exercise is more effective when supervised 1

Heat/Cold Therapy

• Apply local heat (e.g., paraffin wax, hot packs) before exercise to relieve pain and stiffness 2
• Cold therapy can be used for acute pain flares (20 minutes with periodic interruptions) 2

Patient Education

• Strongly recommended by multiple guidelines 1
• Should include:
  • Information about the condition and its management
  • Joint protection techniques
  • Ergonomic principles
  • Pacing of activities 1

Pharmacological Management

Topical NSAIDs

• First-line pharmacological treatment 2
• Strongly recommended for hand OA 1
• Safer profile than oral NSAIDs, especially in older adults 1

Oral Analgesics

• Paracetamol (acetaminophen) as first oral analgesic for mild to moderate pain 2
• Oral NSAIDs if topical NSAIDs and paracetamol are ineffective 1, 2
  • Use lowest effective dose for shortest duration
  • Monitor for side effects, especially in older adults
  • Contraindicated in certain comorbidities

Intra-articular Injections

• Corticosteroid injections for painful flares 1
  • Provides short-term relief (approximately 1 month) but not long-term benefit
  • Consider for acute symptom flares unresponsive to other treatments
• Hyaluronic acid injections may be considered 1
  • May have more prolonged benefit than corticosteroids
  • Evidence is limited but promising

Treatment Algorithm

1. Initial approach:

   • First CMC joint orthosis (neoprene or rigid)
   • Topical NSAIDs
   • Patient education and exercise therapy

2. If inadequate response after 4-6 weeks:

   • Add oral paracetamol
   • Consider heat/cold therapy
   • Evaluate exercise technique and orthosis fit

3. For persistent symptoms:

   • Consider oral NSAIDs (if not contraindicated)
   • Evaluate for intra-articular corticosteroid injection

4. For severe, refractory symptoms:

   • Consider surgical options when conservative treatments fail
   • Surgical options include trapeziectomy, arthroplasty, or arthrodesis 1, 2

Monitoring and Follow-up

• Follow-up in 4-6 weeks to evaluate response to treatment 2
• Monitor for medication side effects, particularly with oral NSAIDs 2
• Evaluate ability to perform activities of daily living 2

Common Pitfalls and Caveats

• Radiographs are not routinely needed but may be considered to rule out other pathologies 2
• Don't rely solely on oral NSAIDs without trying topical preparations first
• Avoid prolonged immobilization which can lead to stiffness and weakness
• Don't delay referral for surgical evaluation when conservative measures fail after 3-6 months
• Remember that approximately 80% of patients improve with appropriate conservative management 2

Special Considerations

• CMC joint OA is more common in postmenopausal women 3, 4
• In patients older than 75 years, thumb CMC osteoarthritis has a radiographic prevalence of 25% in men and 40% in women 4
• Surgical options should be considered only after failure of conservative management 1, 2