What is the evaluation and treatment for persistent pain at the base of the thumb and lateral wrist that worsens with thumb movement for 6 months?

Evaluation and Management of Chronic Thumb Base and Lateral Wrist Pain

Begin with standard three-view radiographs (posteroanterior, lateral, and oblique) of the hand and wrist, as this is the most appropriate initial imaging study and will likely establish the diagnosis of thumb carpometacarpal (CMC) osteoarthritis in this clinical presentation. 1

Initial Diagnostic Evaluation

Clinical Assessment

• Localize pain through palpation to the base of the thumb (trapeziometacarpal joint), which is the second most common site of hand osteoarthritis 2
• Perform the grind test (axial compression with rotation of the thumb metacarpal on the trapezium) to provoke symptoms specific to thumb base arthritis 3, 4
• Assess for activity-related pain, particularly with forceful pinch or gripping activities, which is characteristic of basal thumb arthritis 4, 2

Imaging Protocol

• Standard radiographs are essential and sufficient for diagnosis in most cases, showing joint space narrowing, osteophytes, and subluxation patterns 1
• Advanced imaging (MRI, CT, ultrasound) is not indicated as initial evaluation unless radiographs are normal or show only nonspecific findings 1
• Radiographs allow Eaton-Littler staging which guides treatment planning 2

Treatment Algorithm

First-Line Conservative Management (Initiate Simultaneously)

Splinting is strongly recommended as primary treatment, specifically using a full splint that covers both the thumb base AND wrist, as this provides superior pain relief compared to thumb-only splints (NNT = 4 for improving daily activities) 1

Topical NSAIDs are the preferred pharmacological treatment for mild to moderate pain, as they provide equivalent pain relief to oral NSAIDs (effect size 0.77) without increased gastrointestinal complications 1

Activity modification should be implemented immediately, focusing on avoiding forceful pinch and repetitive thumb loading 4

Second-Line Pharmacological Options

• Oral paracetamol (up to 4g/day) if topical NSAIDs are insufficient, as it has the best safety profile 1
• Oral NSAIDs at the lowest effective dose for shortest duration if paracetamol fails 1
• Add gastroprotection (PPI or H2-blocker) with oral NSAIDs in patients with GI risk factors 1
• Avoid COX-2 inhibitors in patients with cardiovascular risk factors 1

Interventional Treatment

Intra-articular corticosteroid injection may provide short-term benefit for painful flares, though evidence is limited and effects may not persist beyond one month 1

• Note: Evidence for corticosteroid injection efficacy is inconclusive (one underpowered RCT showed no benefit) 1
• Intra-articular hyaluronan is an alternative with potentially more prolonged benefit than corticosteroid 1

Surgical Intervention

Surgery should be considered when conservative treatments fail AND the patient has marked pain and/or disability affecting quality of life 1

Trapeziectomy alone is the recommended surgical approach, as combination procedures (trapeziectomy with ligament reconstruction and tendon interposition) provide no additional benefit but cause significantly more complications (RR 2.12,95% CI 1.24-3.60) 1, 5

• Multiple surgical options exist (arthrodesis, osteotomy, arthroplasty, total joint replacement), but no technique has proven superiority over simple trapeziectomy 1, 2, 5
• Combination procedures should be avoided due to higher complication rates without improved outcomes 1, 5

Common Pitfalls

• Do not order MRI or advanced imaging initially unless radiographs are normal, as this adds cost without diagnostic benefit 1
• Do not use thumb-only splints when a full splint including the wrist provides better pain control 1
• Do not proceed directly to oral NSAIDs without first trying topical NSAIDs, which have equivalent efficacy with better safety profiles 1
• Do not perform complex surgical procedures when simple trapeziectomy provides equivalent outcomes with fewer complications 1, 5