What are the treatment options for wrist arthritis?

Treatment Options for Wrist Arthritis

For wrist arthritis, treatment should combine non-pharmacological and pharmacological approaches, with splinting/orthoses, topical treatments, and hand therapy exercises as first-line options before considering more invasive interventions. 1

Non-Pharmacological Treatments

Physical Therapy and Exercise

• Hand therapy exercises are conditionally recommended for patients with hand/wrist involvement to improve pain and physical function 1
• Consistent engagement in exercise (aerobic, resistance, and mind-body) is strongly recommended for patients with rheumatoid arthritis affecting the wrist 1
• Range of motion and strengthening exercises should be incorporated into treatment plans for all patients with wrist arthritis 1

Splinting and Orthoses

• Splints for thumb base osteoarthritis and orthoses to prevent/correct lateral angulation and flexion deformity are recommended with moderate strength of evidence 1
• For patients with hand/wrist involvement or deformity, use of splinting, orthoses, and/or compression is conditionally recommended over no intervention 1
• Full splints covering both thumb base and wrist provide more pain relief than half splints that only protect the thumb base in patients with first carpometacarpal osteoarthritis 1

Heat Therapy and Ultrasound

• Local application of heat (paraffin wax, hot packs) is beneficial, especially before exercise, with moderate strength of recommendation 1
• Ultrasound therapy has limited evidence supporting its use for hand osteoarthritis and is not generally recommended 1

Joint Protection and Activity Modification

• Joint protection techniques are conditionally recommended to improve pain and function 1
• Education about avoiding adverse mechanical factors should be provided to all patients with wrist arthritis 1
• Activity pacing, energy conservation, and fatigue management are conditionally recommended despite limited evidence 1

Pharmacological Treatments

Topical Treatments

• Local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are affected 1
• Topical NSAIDs are effective for pain relief in hand osteoarthritis with efficacy equal to oral NSAIDs but with fewer gastrointestinal side effects 1
• Topical capsaicin is effective for hand osteoarthritis with a number needed to treat of 3 for clinical improvement within 4 weeks 1

Oral Medications

• Paracetamol (up to 4 g/day) is the oral analgesic of first choice due to its efficacy and safety profile 1
• Oral NSAIDs should be used at the lowest effective dose and for the shortest duration in patients who respond inadequately to paracetamol 1
• In patients with increased gastrointestinal risk, non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor should be used 1
• For rheumatoid arthritis affecting the wrist, disease-modifying antirheumatic drugs like methotrexate may be indicated 2

Intra-articular Treatments

• Intra-articular injection of long-acting corticosteroid is effective for painful flares of osteoarthritis, especially in the trapeziometacarpal joint 1
• Intra-articular hyaluronan may be useful in treating trapeziometacarpal osteoarthritis with potentially more prolonged benefit than corticosteroid injections 1

Surgical Options

For Moderate to Severe Disease

• Surgery should be considered in patients with marked pain and/or disability when conservative treatments have failed 1
• For rheumatoid arthritis affecting the wrist, surgical options include synovectomy, tendon reconstruction, distal ulnar resection, partial or full wrist arthrodesis, and total wrist arthroplasty 3
• Arthroscopic synovectomy is recommended for pain relief and functional recovery in early-stage rheumatoid arthritis and can be helpful in Larsen stage III 4
• For severe thumb base osteoarthritis, interposition arthroplasty, osteotomy, or arthrodesis are effective treatments 2

Diagnostic Imaging

• Radiography is usually appropriate as the initial imaging study for chronic hand or wrist pain 1
• For chronic wrist pain following normal radiographs or radiographs showing nonspecific arthritis, MRI without IV contrast or MR arthrography is usually appropriate as the next imaging study 1
• Ultrasound or MRI without IV contrast is appropriate when there is concern for tendon injury, tenosynovitis, or tendon pathology 1

Treatment Algorithm Based on Disease Severity

Mild Wrist Arthritis

1. Education on joint protection and activity modification 1
2. Heat therapy before exercise 1
3. Hand therapy exercises focusing on range of motion and strengthening 1
4. Splinting/orthoses for support and pain relief 1
5. Topical NSAIDs or capsaicin for pain management 1

Moderate Wrist Arthritis

1. Continue all treatments for mild arthritis
2. Add paracetamol for pain management 1
3. Consider intra-articular corticosteroid injections for flares 1
4. If inadequate response to paracetamol, add oral NSAIDs at lowest effective dose 1
5. Consider referral to occupational or physical therapy for comprehensive treatment 1

Severe Wrist Arthritis

1. Continue appropriate conservative measures
2. Consider disease-modifying antirheumatic drugs if rheumatoid arthritis 2
3. Evaluate for surgical intervention if significant pain and disability persist despite conservative management 2, 3
4. Surgical options based on specific pathology and patient factors 5, 6

Common Pitfalls and Caveats

• Failure to distinguish between different types of wrist arthritis (osteoarthritis, rheumatoid arthritis, post-traumatic) may lead to suboptimal treatment 1
• Overreliance on oral NSAIDs without appropriate gastroprotection can lead to significant gastrointestinal complications 1
• Delaying referral for specialized hand therapy may result in preventable loss of function 1
• Inadequate splinting or improper orthosis fit may worsen symptoms or create new problems 1
• Focusing solely on pain management without addressing joint protection and function can lead to progressive joint damage 1