What is the initial management approach for joint deformity in the hands, specifically due to conditions like rheumatoid arthritis?

Initial Management of Hand Joint Deformity

For hand joint deformities, immediately initiate education on joint protection techniques combined with range of motion and strengthening exercises, apply first carpometacarpal (CMC) joint splints for thumb involvement, and start topical or oral NSAIDs for pain control. 1

Immediate Assessment Priorities

When evaluating hand joint deformities, specifically examine for:

• Joint distribution pattern: Distal interphalangeal (DIP), proximal interphalangeal (PIP), and thumb base joints are characteristic of osteoarthritis, while metacarpophalangeal (MCP) joints with ulnar drift suggest rheumatoid arthritis 1
• Presence of Heberden nodes (DIP) or Bouchard nodes (PIP) indicating osteoarthritic changes 1
• Ulnar deviation of fingers, palmar subluxation, swan-neck or boutonnière deformities suggesting inflammatory arthritis 2, 3
• Skin changes: scleroderma, rosacea, or other systemic disease markers 1
• Functional impairment severity using validated outcome measures, as hand OA disability can equal that of rheumatoid arthritis 1

Non-Pharmacologic First-Line Interventions

Education and Exercise (Mandatory for All Patients)

• Provide joint protection instruction focusing on avoiding adverse mechanical forces during daily activities 1
• Prescribe home-based range of motion exercises for all affected joints 1
• Add strengthening exercises targeting forearm and hand musculature 1
• The combination of education plus exercise shows a number needed to treat of 2 for functional improvement, though individual components lack robust evidence in isolation 1

Splinting and Orthoses

• Strongly recommend first CMC joint orthoses for thumb base involvement 1, 4
• Apply trapeziometacarpal joint splints for thumb deformities 1
• Splints for other hand joints are conditionally recommended based on individual joint involvement 1, 4

Thermal Modalities

• Apply local heat (paraffin wax, hot packs) before exercise sessions to facilitate range of motion 1
• Heat application has strong expert consensus support despite limited hand-specific trial data 1

Pharmacologic Management Algorithm

Step 1: Topical Therapy

• Start with topical NSAIDs as first-line pharmacologic treatment for accessible hand joints 1
• Topical capsaicin is conditionally recommended as an alternative 1

Step 2: Oral Medications

If topical therapy provides inadequate relief:

• Initiate oral NSAIDs at the lowest effective dose for shortest duration 1, 4
• For patients with gastrointestinal risk factors, use COX-2 selective inhibitors or combine nonselective NSAIDs with proton pump inhibitors 1, 5
• Acetaminophen (up to 4,000 mg/day) can be used as initial therapy in patients with NSAID contraindications, though efficacy is lower 5, 4

Step 3: Additional Pharmacologic Options

For inadequate response to initial therapy:

• Tramadol is conditionally recommended when other options fail 1, 4
• Duloxetine (30-60 mg/day) is conditionally recommended, particularly with comorbid depression 5, 4

Step 4: Intra-articular Injections

• Intra-articular corticosteroid injections are conditionally recommended for persistent symptoms or acute flares in larger hand joints 1

Critical Contraindications and Monitoring

• Avoid oral NSAIDs in patients with history of gastrointestinal bleeding or significant cardiovascular disease 5
• Monitor for NSAID-related gastrointestinal and cardiovascular adverse effects throughout treatment 5
• Do not use glucosamine or chondroitin sulfate as evidence does not support efficacy 5, 4
• Avoid long-term opioid therapy as evidence does not support use in OA management 5

Special Considerations for Inflammatory Arthritis

If clinical features suggest rheumatoid arthritis (MCP involvement, ulnar drift, inflammatory symptoms):

• Immediate rheumatology referral is essential 6
• Start disease-modifying antirheumatic drugs (DMARDs) immediately, with methotrexate as first-line therapy 6, 7
• Early aggressive treatment prevents irreversible joint destruction and disability 6, 7
• Synovectomy or silastic joint replacement may be indicated for severe MCP joint destruction 2

Erosive Hand Osteoarthritis Recognition

For patients with:

• Abrupt onset with marked pain and inflammatory signs (stiffness, soft tissue swelling, erythema) 1
• Radiographic subchondral erosion at interphalangeal joints 1
• Mildly elevated C-reactive protein 1

This subset requires more aggressive monitoring and management as it has worse outcomes than non-erosive hand OA 1