What are the treatment options for a patient with wrist arthritis?

Treatment of Wrist Arthritis

Start with non-pharmacological interventions including hand therapy exercises and splinting, then progress to topical NSAIDs, followed by oral analgesics (paracetamol first, then oral NSAIDs), and reserve intra-articular corticosteroid injections for painful flares, with surgery only for refractory cases with marked disability. 1, 2, 3

Initial Non-Pharmacological Management

Begin with these conservative measures as first-line therapy:

• Hand therapy exercises are strongly recommended to improve pain and physical function, incorporating range of motion and strengthening exercises into all treatment plans 1
• Consistent engagement in exercise programs including aerobic, resistance, and mind-body exercises should be prescribed 1
• Splinting provides significant benefit - full splints covering both wrist and thumb base provide more pain relief than partial splints, with moderate strength of evidence supporting orthoses to prevent lateral angulation and flexion deformity 1
• Apply local heat (paraffin wax or hot packs) before exercise sessions for symptomatic relief 1, 3
• Teach joint protection techniques and educate patients about avoiding adverse mechanical factors 1

Pharmacological Treatment Algorithm

Progress through medications in this specific order:

Step 1: Topical Agents (Preferred Initial Pharmacotherapy)

• Topical NSAIDs are the first-line pharmacological treatment for mild to moderate pain affecting a few joints, with efficacy equal to oral NSAIDs but fewer gastrointestinal side effects 1, 2, 3
• Topical capsaicin is effective with a number needed to treat of 3 for clinical improvement within 4 weeks 1

Step 2: Oral Analgesics

• Paracetamol (up to 4g/day) is the first oral analgesic choice due to its efficacy and safety profile 1, 2, 3
• Only prescribe oral NSAIDs when patients respond inadequately to paracetamol and topical NSAIDs 2, 3

Step 3: Risk-Stratified Oral NSAID Selection

When oral NSAIDs become necessary, mandatory cardiovascular and gastrointestinal risk stratification must be performed before prescribing 2:

• For patients with increased gastrointestinal risk: prescribe non-selective NSAIDs plus gastroprotective agents OR selective COX-2 inhibitors 2, 3
• For patients with increased cardiovascular risk: COX-2 inhibitors are contraindicated; use non-selective NSAIDs with extreme caution 2, 3
• Always use the lowest effective dose for the shortest duration necessary 1, 2, 3

Step 4: Invasive Non-Surgical Treatment

• Intra-articular corticosteroid injections are effective for painful flares, especially in the trapeziometacarpal joint, and should be considered when conservative measures provide inadequate relief 1, 3
• Failure of corticosteroid injections indicates consideration for surgical intervention 3

Surgical Management

Reserve surgery only for patients with marked pain and/or disability limiting activities of daily living AND who have failed all conservative treatments 3:

• Wrist arthroscopy and denervation offer shorter recovery time and motion preservation, though duration of effectiveness varies 4
• Total wrist denervation is satisfactory for patients with good range of motion and low functional demands, particularly elderly patients 5
• Proximal row carpectomy and four-corner fusion are the most widely used procedures for stage II wrist osteoarthritis secondary to SLAC or SNAC wrist 5
• Total wrist arthrodesis is effective for heavy manual laborers with wrist stiffness or generalized wrist-joint involvement 5
• Total wrist arthroplasty may be considered in lower-demand patients with pancarpal arthrosis 4

Diagnostic Imaging Approach

• Radiography is the initial imaging study for chronic wrist pain 1
• Following normal radiographs or nonspecific arthritis findings, MRI without IV contrast or MR arthrography is the next appropriate study 1
• Use ultrasound or MRI without IV contrast when tendon injury, tenosynovitis, or tendon pathology is suspected 1

Critical Pitfalls to Avoid

• Never prescribe oral NSAIDs as first-line therapy when topical options have not been tried, especially in elderly patients or those with multiple comorbidities 2
• Do not continue oral NSAIDs indefinitely without periodic reassessment of efficacy, necessity, and emerging risk factors 2
• Never proceed to surgery without exhausting conservative measures first - the evidence-based algorithm mandates stepwise progression through non-pharmacological, pharmacological, and invasive non-surgical options 3
• Do not skip cardiovascular and gastrointestinal risk assessment before initiating any oral NSAID therapy 2