What is the initial management for osteoarthritis (OA) affecting the distal interphalangeal (DIP) joints shown on X-ray?

Initial Management of Osteoarthritis in Distal Interphalangeal (DIP) Joints

The initial management for osteoarthritis affecting the DIP joints shown on X-ray should include hand orthoses/splinting combined with topical NSAIDs as first-line treatment. 1

Non-pharmacological Interventions

Splinting/Orthoses

• Custom-made splints specifically designed for DIP joints have been shown to reduce pain by up to 66% 2
• Splints should be:
  • Easily detachable to preserve finger pad sensation
  • Designed to not interfere with proximal interphalangeal joint motion
  • Fitted by an occupational therapist for proper fit and function 1

Exercise Therapy

• Include active finger motion exercises, range of motion exercises, and strengthening exercises 1
• Supervised exercise programs are more effective than unsupervised ones
• Exercise should be individualized according to the patient's specific needs and joint involvement

Patient Education

• Provide information about:
  • Joint protection techniques to minimize stress on affected joints
  • Ergonomic principles for daily activities
  • Pacing of activities to prevent overuse 1
  • Nature of OA as a repair process triggered by various insults 3

Pharmacological Management

First-line:

• Topical NSAIDs - safer profile than oral medications, especially in older adults 1

Second-line (if topical NSAIDs insufficient):

• Oral acetaminophen/paracetamol for mild to moderate pain 1

Third-line:

• Oral NSAIDs at lowest effective dose for shortest duration with monitoring for side effects 1
  • Naproxen has been shown to be effective for osteoarthritis with fewer gastrointestinal side effects than aspirin or indomethacin 4

Other considerations:

• Chondroitin sulfate may be considered, though evidence for hand OA is limited 3
• Intra-articular glucocorticoid injections may be considered for painful interphalangeal joints, though not generally recommended for hand OA 3

Follow-up and Monitoring

• Evaluate response to treatment in 4-6 weeks 1
• Monitor for medication side effects, particularly with oral NSAIDs
• Assess ability to perform activities of daily living and provide assistive devices as needed

Surgical Options (when conservative management fails)

• Surgical options should only be considered when non-pharmacological and pharmacological treatments have failed to provide adequate pain relief 3
• For DIP joints specifically, arthrodesis (joint fusion) is the recommended surgical approach 3
• Alternative surgical options with less evidence include:
  • DIP joint arthroplasty - preserves motion but has 15% complication rate 5
  • Open cheilectomy - can improve range of motion and reduce pain while preserving joint motion 6

Common Pitfalls and Caveats

1. Delaying non-pharmacological interventions: Many clinicians focus solely on medications while overlooking the importance of splinting and exercise.
2. Overuse of oral NSAIDs: These carry significant risks, especially in older patients. Always start with topical NSAIDs.
3. Inadequate splinting: Poorly fitted splints can worsen symptoms or lead to poor compliance.
4. Rushing to surgical options: Exhaust all conservative options before considering surgery.
5. Overlooking occupational factors: Certain occupations or hobbies (like musicians 7) may require specialized approaches to maintain function.

By following this comprehensive approach, most patients with DIP joint osteoarthritis can achieve significant pain relief and functional improvement without requiring surgical intervention.