What is the next step in managing a patient with carpometacarpal joint degenerative joint disease (DJD)?

Management of Carpometacarpal Joint Degenerative Joint Disease

For patients with carpometacarpal joint degenerative joint disease (DJD), a hand orthosis is strongly recommended as the first-line treatment approach. 1

Initial Conservative Management

Orthotic Devices

• First carpometacarpal (CMC) joint orthoses (either neoprene or rigid) are strongly recommended for symptom relief in patients with thumb base osteoarthritis 1
• Long-term use of orthoses is advocated as studies show beneficial effects on pain and function when used for at least 3 months 1
• Custom-made orthoses are preferable to improve patient compliance, though both custom-made and prefabricated options are available 1

Exercise Therapy

• Hand exercises should be implemented to improve joint mobility, muscle strength, and thumb base stability 1
• Exercises specifically aimed at the first carpometacarpal joint differ from those for interphalangeal joints 1
• Exercise regimens should be supervised for better outcomes and should include strengthening exercises 1

Education and Self-Management

• Patient education about osteoarthritis, its management options, and ergonomic principles is strongly recommended 1
• Training in joint protection techniques and pacing activities should be included 1
• Self-management programs to enhance understanding of the condition and improve coping strategies 1

Topical Treatments

• Topical NSAIDs are conditionally recommended for hand OA, including CMC joint involvement 1
• Practical considerations (e.g., frequent hand washing) may limit the effectiveness of topical NSAIDs for hand OA 1

Pharmacological Management

Oral Medications

• Oral NSAIDs are strongly recommended for short-term use unless contraindicated 1
• Prescribe at low doses for short periods and discontinue if not effective, while monitoring for side effects 1
• Acetaminophen may be considered as an alternative, though it has limited efficacy 1

Advanced Interventions

Intra-articular Injections

• Intra-articular glucocorticoid injections are conditionally recommended for hand OA, including CMC joint involvement 1
• These injections can provide temporary relief during acute pain flares 1

Surgical Considerations

• Surgery should be considered when there is radiographic evidence of OA, marked disability, reduced quality of life, and other treatment modalities have been unsuccessful in relieving pain 1
• Surgical options include denervation, which has shown good pain relief and improvement in grip strength in selected patients 2
• Resection arthroplasty (trapeziectomy) is another option for advanced cases that don't respond to conservative management 3

Common Pitfalls and Caveats

• Avoid delaying orthotic intervention, as early use can provide symptom relief and potentially slow progression 4
• Don't rely solely on radiographic findings, as clinical symptoms may not correlate with imaging severity 1
• Recognize that untreated scapho-trapezoid arthrosis after resection-suspension arthroplasty of the CMC joint may not be clinically relevant in many patients 5
• Understand that while kinesiotaping permits range of motion (unlike braces), evidence quality is limited by inability to blind participants in studies 1

Treatment Algorithm

1. First-line: Hand orthosis (preferably custom-made) + exercise therapy + education 1
2. Second-line: Add topical NSAIDs 1
3. Third-line: Short course of oral NSAIDs if no contraindications 1
4. Fourth-line: Intra-articular glucocorticoid injections for acute flares 1
5. Fifth-line: Surgical consultation for patients with persistent symptoms despite conservative management 1

By following this evidence-based approach, most patients with carpometacarpal joint DJD can achieve significant symptom relief and functional improvement.