What is the initial management for degenerative changes of the Carpometacarpal (CMC) joint?

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

Hand orthoses (splinting) are strongly recommended as the initial management for degenerative changes of the first CMC joint, combined with topical NSAIDs as first-line pharmacological treatment. 1, 2

First-Line Conservative Management

Orthotic Devices

• Hand orthoses/splints:
  • Custom-made neoprene or rigid rest orthosis worn at night is most effective 2
  • Specifically designed to stabilize the first CMC joint while allowing functional use of the hand
  • Patients will benefit from evaluation by an occupational therapist for proper fitting 1

Pharmacological Treatment

1. Topical NSAIDs:

   • First-line pharmacological treatment
   • Safer profile than oral medications, especially in older adults 2
   • Apply directly to the affected area 3-4 times daily

2. Oral medications (if topical treatments are insufficient):

   • Acetaminophen (paracetamol) - second-line option
   • Oral NSAIDs - third-line option, used at lowest effective dose for shortest duration 2

Exercise Therapy

• Supervised exercise programs are more effective than unsupervised 2
• Include:
  • Active finger motion exercises
  • Range of motion exercises to maintain joint mobility
  • Strengthening exercises to stabilize the joint
  • Joint protection techniques

Patient Education

• Information about the condition and its management
• Joint protection techniques to minimize stress on affected joints
• Ergonomic principles for daily activities
• Pacing of activities to reduce joint strain 2

Follow-up and Monitoring

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

When to Consider Advanced Interventions

• If conservative management fails after 3-6 months:
  • Consider corticosteroid injections
  • Evaluate for surgical options including trapeziectomy, arthroplasty, or arthrodesis 3, 4

Important Considerations

• CMC joint OA is more common in postmenopausal women (radiographic prevalence of 40% in women over 75 years compared to 25% in men) 2
• Approximately 80% of patients recover with appropriate conservative treatment within 3-6 months 2
• Surgery should only be considered after failure of a comprehensive trial of conservative management 3

Common Pitfalls to Avoid

1. Rushing to surgical intervention before adequate trial of conservative management
2. Using oral NSAIDs as first-line treatment instead of topical NSAIDs
3. Failing to provide proper education on joint protection techniques
4. Not referring to occupational therapy for proper orthosis fitting
5. Overlooking the importance of exercise therapy in management

By following this structured approach to managing CMC joint degeneration, most patients can achieve significant pain relief and functional improvement without requiring surgical intervention.