What is the treatment plan for an elderly female with progressive right hand swelling over two months, with a history of osteoarthritis (OA)?

Treatment Plan for Progressive Right Hand Swelling in Elderly Female with Osteoarthritis

The treatment plan should begin with a thorough diagnostic evaluation to rule out acute pathology (fracture, infection, inflammatory arthritis) before attributing symptoms solely to osteoarthritis, followed by a multimodal approach combining non-pharmacological interventions (hand exercises, joint protection) with topical NSAIDs as first-line pharmacologic therapy. 1, 2

Immediate Diagnostic Evaluation

Progressive swelling over two months in a single hand requires exclusion of alternative diagnoses before proceeding with OA-specific treatment:

• Obtain radiographs (AP, lateral, and oblique views) of the right hand to assess for occult fractures, joint space narrowing, osteophytes, and rule out other pathology given the significant swelling and progressive nature 2
• Perform vascular and neurological examination to assess distal pulses, capillary refill, sensation, and motor function to exclude compartment syndrome or nerve compression 2
• Consider laboratory testing (CBC, ESR, CRP, rheumatoid factor, anti-CCP) if inflammatory arthritis is suspected, particularly if there is prolonged morning stiffness (>30 minutes), constitutional symptoms, or involvement of multiple joints 3, 4

Non-Pharmacological Interventions (First-Line)

These form the foundation of OA management and should be initiated immediately:

• Implement a supervised hand exercise program focusing on range-of-motion and strengthening exercises adapted to the patient's functional capacity, as exercise is strongly recommended by the American College of Rheumatology for all OA patients 1, 5, 2
• Provide patient education through self-efficacy and self-management programs to help the patient understand their condition, develop coping strategies, and learn joint protection techniques 1, 6, 2
• Recommend joint protection strategies including activity modification, energy conservation techniques, and use of assistive devices (jar openers, built-up handles on utensils) to reduce joint stress 2
• Consider occupational therapy referral for hand-specific interventions, splinting if indicated, and workplace/home adaptations 1, 3

Pharmacological Management Algorithm

Start with the least systemic exposure and escalate as needed:

Step 1: Topical Therapy (First-Line Pharmacologic)

• Apply topical NSAIDs (diclofenac 2% gel) twice daily to clean, dry skin of the affected hand, as the American College of Rheumatology strongly recommends topical NSAIDs for OA with effective pain relief and minimal systemic exposure 5, 2

Step 2: Oral Acetaminophen (Second-Line)

• If topical NSAIDs provide insufficient relief, add oral acetaminophen up to 3,000-4,000 mg/day (ensuring no other acetaminophen-containing medications are being used), as it provides pain relief with minimal systemic effects 1, 6, 2

Step 3: Oral NSAIDs (Third-Line)

• Use oral NSAIDs at the lowest effective dose for the shortest duration if acetaminophen is inadequate, carefully considering cardiovascular and gastrointestinal risks in this elderly patient 1, 2
• COX-2 selective inhibitors may be preferred if there is increased gastrointestinal bleeding risk 3

Step 4: Alternative Agents

• Consider duloxetine if there is inadequate response to first-line treatments or if comorbid depression is present 5

Weight Management (If Applicable)

• If the patient is overweight or obese, recommend weight loss of 5-10% of body weight through diet and exercise, as this can significantly improve pain and function even in hand OA by reducing systemic inflammation 5, 2

Follow-Up Schedule

• Short-term evaluation (1-2 weeks): Assess swelling reduction, skin condition, and initial response to topical therapy 2
• Medium-term evaluation (4-6 weeks): Evaluate response to pharmacologic interventions, progress with exercises, and need for treatment escalation 2
• Long-term evaluation (3-6 months): Reassess functional status and consider referral to hand surgery if severe symptoms persist despite optimal conservative management 1, 2

Critical Pitfalls to Avoid

• Do not assume all hand swelling in an elderly patient with OA is due to osteoarthritis alone—inflammatory arthritis, crystal arthropathy (gout, pseudogout), or infection must be excluded, particularly with progressive unilateral swelling 2, 4
• Avoid recommending glucosamine, chondroitin, or other unproven supplements as the American Academy of Orthopaedic Surgeons explicitly does not recommend these due to insufficient evidence 5
• Do not delay diagnostic imaging—occult fractures or other pathology may be present despite a history of OA 2
• Ensure the patient is not taking multiple acetaminophen-containing products to avoid hepatotoxicity when prescribing acetaminophen 2
• Monitor for NSAID-related complications (gastrointestinal bleeding, cardiovascular events, renal dysfunction) in elderly patients, particularly with prolonged use 1, 2, 3