What are the treatment options for first metacarpal joint swelling?

Treatment Options for First Metacarpal Joint Swelling

The treatment of first metacarpal joint swelling should follow a stepwise approach, beginning with conservative measures and progressing to more invasive interventions if symptoms persist or worsen.

Diagnosis and Initial Assessment

• First metacarpal joint swelling may indicate early arthritis, especially when accompanied by pain, stiffness, or limited range of motion 1, 2
• Clinical examination is the primary method for detecting synovitis, with ultrasound, power Doppler, and MRI helpful in doubtful cases 1, 2
• The "squeeze test" (lateral compression of metacarpophalangeal joints causing pain) can help identify involvement of hand joints 1, 2
• Laboratory tests should include complete blood count, urinary analysis, transaminases, and antinuclear antibodies to exclude other diseases 1

Conservative Management Options

• Non-steroidal anti-inflammatory drugs (NSAIDs) should be considered for symptomatic relief after evaluation of gastrointestinal, renal, and cardiovascular status 1
• Splinting and education on joint protection techniques can help reduce pain and prevent deformity 3
• Physical therapy interventions including dynamic exercises may be beneficial as adjuncts to pharmaceutical treatments 1
• Topical anti-inflammatory medications such as diclofenac sodium can provide localized relief with fewer systemic effects 4

Pharmacological Interventions

• For inflammatory arthritis affecting the first metacarpal joint, early initiation of disease-modifying antirheumatic drugs (DMARDs) is recommended, with methotrexate considered the anchor drug 1
• Systemic glucocorticoids can reduce pain and swelling and should be considered as temporary adjunctive treatment 1
• Intra-articular corticosteroid injections are effective for painful flares, especially in trapeziometacarpal (first carpometacarpal) joint osteoarthritis 1
• Intra-articular hyaluronan may be useful in treating trapeziometacarpal osteoarthritis, with some evidence suggesting it may provide more prolonged benefit than corticosteroid injections 1

Surgical Options

• Surgery should be considered for severe thumb base osteoarthritis when conservative treatments have failed 1
• Surgical options include trapeziectomy, arthrodesis, interposition arthroplasty, osteotomy, and total joint replacement 1
• For inflammatory arthritis affecting metacarpophalangeal joints, arthroplasty is the most common treatment option for the fingers 4
• For the thumb metacarpophalangeal joint specifically, arthrodesis is generally a reliable surgical solution 4
• Evidence suggests that simpler surgical procedures (e.g., trapeziectomy alone) may be as effective as more complex combined procedures while causing fewer side effects 1

Treatment Algorithm

1. Begin with NSAIDs and activity modification/joint protection 1, 3
2. Add splinting and physical therapy interventions 1, 3
3. For persistent symptoms, consider intra-articular corticosteroid injection 1
4. For inflammatory arthritis, initiate DMARDs early, particularly if risk factors for persistent disease are present 1
5. Consider intra-articular hyaluronan for trapeziometacarpal osteoarthritis 1
6. For severe cases unresponsive to conservative management, refer for surgical evaluation 1, 4

Special Considerations

• Regular monitoring of disease activity and adverse events should guide decisions on treatment changes 1
• First carpometacarpal (trapeziometacarpal) osteoarthritis is particularly common in postmenopausal women and typically presents bilaterally 5
• Differential diagnosis should include tenosynovitis, crystal arthropathies, and less common conditions like synovial chondromatosis 5, 6
• For acute traumatic causes of first metacarpal joint swelling, such as sprains, different treatment protocols may be needed, including surgical intervention if the joint is unstable or if bony fragments are displaced 7