What treatment options are available for severe arthritis in a bent finger, as shown on an X-ray?

Treatment of Severe Finger Arthritis with Deformity

For severe finger arthritis with deformity visible on X-ray, begin with a stepwise conservative approach including activity modification, splinting, topical NSAIDs, oral analgesics, and hand exercises; if these fail after 3+ months and the patient has marked pain or disability limiting daily activities, proceed to surgical options including arthrodesis (fusion) for distal interphalangeal joints or arthroplasty (joint replacement) for metacarpophalangeal joints. 1, 2, 3

Initial Conservative Management (First 3 Months)

Start with multimodal conservative therapy, which should include all of the following:

• Activity modification and education about avoiding repetitive gripping or pinching motions that stress the affected joints 1, 4
• Splinting to rest the affected joints, particularly during activities or at night 2, 3
• Heat application using paraffin wax or hot packs before exercise sessions to reduce stiffness 4, 5
• Exercise regimens combining range-of-motion exercises to prevent stiffness and strengthening exercises to maintain grip function 4, 5, 3

Pharmacological Options

Topical and Oral Medications

• Topical NSAIDs are effective and safe for mild-to-moderate pain, especially when only a few fingers are affected 4
• Oral paracetamol (up to 4g/day) is the first-choice oral analgesic due to its efficacy and safety profile 4
• Oral NSAIDs (such as naproxen) should be used at the lowest effective dose for the shortest duration if paracetamol is inadequate 4, 6
  • In patients with gastrointestinal risk, add gastroprotective agents or use selective COX-2 inhibitors 4
  • In patients with cardiovascular risk, avoid COX-2 inhibitors and use non-selective NSAIDs cautiously 4
  • Be aware that NSAIDs can cause ulcers, bleeding, and cardiovascular events including heart attack and stroke 6

Intra-articular Injections

• Corticosteroid injections can provide short-term pain relief for painful flares, though long-term efficacy is questionable 2, 7
• Consider for temporary relief while awaiting surgical consultation 2

When Conservative Treatment Fails

Define treatment failure as inadequate response after >3 months of appropriate conservative therapy, with >2 months at therapeutic doses of medications (unless toxicity limits dosing) 8

Surgical intervention should be considered when:

• Marked pain and/or disability persist despite conservative treatment 1, 4
• Activities of daily living are significantly limited 1
• Progressive joint damage is evident on X-rays 8

Surgical Options Based on Joint Location

For Distal Interphalangeal (DIP) Joints

• Arthrodesis (joint fusion) is the most effective treatment for symptomatic advanced DIP arthritis 2, 3
• This reliably eliminates pain and provides stability for pinch activities 2, 3
• Loss of motion at the DIP joint is functionally well-tolerated 3

For Proximal Interphalangeal (PIP) and Metacarpophalangeal (MCP) Joints

• Silicone implant arthroplasty remains the gold standard for MCP joints of fingers 2-5 when mobility preservation is desired 2
• Arthrodesis is a reliable option for thumb interphalangeal and MCP joints 2
• Joint replacement allows continued motion but requires careful postoperative rehabilitation 3

For Thumb Base (Carpometacarpal) Arthritis

• Interposition arthroplasty, osteotomy, or arthrodesis are effective surgical options 1
• Surgery should only be considered after failure of conservative treatments including splinting, NSAIDs, and corticosteroid injections 1

Common Pitfalls to Avoid

• Do not proceed to surgery without exhausting conservative measures first - the treatment algorithm requires stepwise progression through non-pharmacological, pharmacological, and invasive non-surgical options 1
• Do not use systemic corticosteroids chronically for finger arthritis due to potential adverse effects 8
• Avoid hydroxychloroquine and gold salts as they are not recommended for peripheral joint arthritis 8
• Do not use NSAIDs long-term without gastroprotection in high-risk patients, and monitor for cardiovascular complications 4, 6
• Do not assume all bent fingers require surgery - many patients achieve adequate symptom control with conservative management alone 2, 9

Disease-Modifying Therapy Consideration

If the bent finger is part of inflammatory arthritis (rheumatoid or psoriatic arthritis) rather than primary osteoarthritis:

• DMARDs such as methotrexate may be indicated to prevent further joint damage 8, 10
• Input from a rheumatologist is essential when initiating DMARD therapy 8
• DMARDs have potential to preserve joint integrity and function in inflammatory arthritis 8

Postoperative Management

After surgical intervention:

• Splinting to protect healing structures 3
• Range-of-motion programs initiated at appropriate intervals to maximize functional outcomes 3
• Strengthening exercises once healing permits to restore grip and pinch strength 3