What is the best management approach for an older adult patient with a history of osteoarthritis, presenting with hand and thumb pain, tingling in the thumb, and X-ray results showing degenerative changes of the radiocarpal joint and distal radioulnar joint (DRUJ), as well as arthritis at the thumb base and triscaphe joint?

Management of Multi-Site Hand and Wrist Osteoarthritis

Begin with core non-pharmacological treatments combined with topical NSAIDs as first-line therapy, escalating to oral analgesics and intra-articular corticosteroid injections for inadequate pain control, while reserving surgical intervention for severe, refractory cases affecting quality of life. 1

Stepwise Treatment Algorithm

First-Line Core Treatments (Initiate Immediately)

• Activity modification and joint protection education should be implemented for all patients with hand and wrist osteoarthritis, as these form the foundation of management 1
• Strengthening exercises and range of motion programs targeting the affected joints (radiocarpal, DRUJ, thumb base, and triscaphe) reduce pain and improve function 1
• Weight loss if overweight or obese addresses a modifiable risk factor that impacts disease progression 1
• Topical NSAIDs (diclofenac sodium topical solution 2%) should be applied to affected areas twice daily as they provide efficacy with lower systemic exposure compared to oral agents 1, 2
• Local heat application can provide symptomatic relief for multiple joint involvement 1
• Assistive devices and supports/braces help protect joints during activities of daily living 1

Second-Line Pharmacological Management

If topical NSAIDs and core treatments provide insufficient relief:

• Acetaminophen (paracetamol) up to 4g daily should be considered, though efficacy in hand/wrist OA is modest 1, 3
• Oral NSAIDs at the lowest effective dose for the shortest duration when topical agents fail, with mandatory proton pump inhibitor co-prescription 1, 3
  • Consider individual cardiovascular and gastrointestinal risk factors before prescribing 1, 3
  • COX-2 inhibitors (other than etoricoxib 60mg) or standard NSAIDs are appropriate first choices 1
• Topical capsaicin can be added as adjunctive therapy for hand osteoarthritis 1

Third-Line Invasive Non-Surgical Options

For moderate to severe pain flares despite pharmacological management:

• Intra-articular corticosteroid injections provide temporary relief (4-8 weeks) and are appropriate for painful exacerbations 1, 3
• Target the most symptomatic joint(s) among the radiocarpal, DRUJ, thumb carpometacarpal, and triscaphe joints 1

Important caveat: Platelet-rich plasma (PRP) cannot be recommended due to inconsistent evidence, lack of standardization in preparation methods, and variable outcomes 4

Fourth-Line Surgical Intervention

Surgical referral is indicated when:

• Joint symptoms (pain, stiffness, reduced function) substantially affect quality of life AND are refractory to non-surgical treatment 1
• Critical timing consideration: Refer before prolonged and established functional limitation develops, as delayed definitive treatment leads to worse outcomes 1, 3

Surgical options by anatomic site:

• Thumb carpometacarpal joint: Interposition arthroplasty, trapeziectomy, or arthrodesis for severe thumb base OA 5
• Radiocarpal and DRUJ: Joint-specific procedures including arthrodesis or arthroplasty depending on functional demands 6
• Triscaphe joint: Fusion procedures or proximal row carpectomy in select cases 6

The EULAR guidelines provide Level III evidence (strength 68,95% CI: 56-79) supporting surgery for severe thumb base OA when conservative measures fail 5

Common Pitfalls to Avoid

• Do not delay surgical referral once conservative management has clearly failed, as this leads to established functional limitation and worse outcomes 1, 3
• Do not operate without exhausting conservative measures first—the treatment algorithm requires stepwise progression through all non-surgical options 5
• Avoid combination therapy with topical and oral NSAIDs unless benefit outweighs risk, and conduct periodic laboratory monitoring if combined therapy is necessary 2
• Do not use arthroscopic lavage and debridement for wrist/hand OA, as this is not supported by evidence 1
• Patient-specific factors (age, sex, comorbidities) should not be barriers to surgical referral when indicated 1

Monitoring Considerations

• For patients on oral NSAIDs: Monitor cardiovascular, gastrointestinal, renal, and hepatic function based on individual risk factors 1, 2
• Reassess treatment efficacy regularly and adjust the therapeutic plan as disease course and patient requirements change over time 7
• When using topical diclofenac: Instruct patients to avoid showering/bathing for 30 minutes after application, wait until area is dry before covering with clothing, and avoid skin-to-skin contact until completely dry 2