What is the best course of treatment for a patient with primary generalized osteoarthritis (OA) of a minor degree, presenting with tenderness at the fifth metacarpophalangeal (MCP) joint, and radiographic findings indicating involvement of the interphalangeal (IP) joints, first carpometacarpal (CMC) joints, and scaphotrapeziotrapezoid (STT) joints, with no erosions, articular calcifications, or loose bodies?

Treatment of Minor Primary Generalized Hand Osteoarthritis with Fifth MCP Joint Tenderness

For this patient with minor primary generalized hand osteoarthritis and fifth MCP joint tenderness, initiate treatment with hand orthoses for symptomatic joints combined with topical NSAIDs, supplemented by instruction in joint protection techniques and thermal modalities, while reserving oral NSAIDs for inadequate response to topical therapy. 1

Initial Non-Pharmacological Management

Hand Orthoses and Splinting

• Hand orthoses are strongly recommended for first CMC joint involvement and conditionally recommended for other hand joints including the fifth MCP joint. 1
• A variety of mechanical supports are available including digital orthoses, ring splints, rigid or neoprene orthoses, and compression gloves that provide warmth and compression. 1
• Patients should be evaluated by an occupational therapist to determine the optimal orthosis type and ensure proper fitting. 1
• Data are insufficient to recommend one specific type of orthosis over another, but the goal is to provide support while maintaining functional range of motion. 1

Joint Protection and Thermal Modalities

• All patients with hand OA should receive instruction in joint protection techniques and be taught to use thermal agents for relief of pain and stiffness. 1
• Paraffin therapy is conditionally recommended specifically for hand OA and can provide symptomatic relief through heat application. 1
• Patients should be evaluated for their ability to perform activities of daily living and provided with assistive devices as necessary. 1

Pharmacological Treatment Algorithm

First-Line: Topical NSAIDs

• Topical NSAIDs are conditionally recommended as first-line pharmacological treatment for hand OA due to their favorable safety profile and minimal systemic exposure. 1
• While the evidence is stronger for knee OA, topical NSAIDs should be considered prior to oral NSAIDs following the principle that medications with the least systemic exposure are preferable. 1
• Practical considerations such as frequent hand washing may limit effectiveness but should still be attempted first. 1

Second-Line: Oral NSAIDs

• Oral NSAIDs are strongly recommended for hand OA when topical therapy provides inadequate relief. 1
• NSAIDs are more effective than acetaminophen for moderate-to-severe pain but carry increased risk of serious upper gastrointestinal adverse events. 2
• Naproxen has been shown to be comparable to aspirin and indomethacin in controlling disease activity with less frequent and severe gastrointestinal and nervous system adverse effects. 3
• Standard dosing of naproxen 375 mg twice daily (750 mg/day) has fewer adverse events than higher doses. 3

Alternative Pharmacological Options

• Intra-articular corticosteroid injections are conditionally recommended for painful flares of hand OA, particularly for first CMC joint involvement. 1
• The evidence for intra-articular corticosteroid in hand OA is limited, with one uncontrolled trial showing short-term benefit at one month but not at 3,6, or 12 months. 1
• Chondroitin sulfate is conditionally recommended though evidence is inconclusive regarding structure-modifying effects in hand OA. 1
• Acetaminophen is conditionally recommended but is less effective than NSAIDs for moderate pain. 1

Additional Therapeutic Considerations

Exercise and Self-Management

• Kinesiotaping is conditionally recommended for first CMC joint OA and permits range of motion unlike rigid braces. 1
• While specific exercise recommendations for hand OA are limited, patients should maintain joint mobility through gentle range-of-motion exercises. 1

Acupuncture

• Acupuncture is conditionally recommended for hand OA though efficacy remains controversial due to issues with blinding, sham controls, and variable study quality. 1

Critical Clinical Pitfalls to Avoid

Distinguishing from Inflammatory Arthritis

• The absence of erosions, articular calcifications, or loose bodies on radiographs supports the diagnosis of primary OA rather than erosive OA or inflammatory arthritis. 1
• Erosive hand OA typically presents with abrupt onset, marked pain, inflammatory symptoms (stiffness, soft tissue swelling, erythema), mildly elevated CRP levels, and radiographic subchondral erosions. 1, 4
• Bilateral symmetric involvement of IP joints is characteristic of generalized OA, not septic arthritis which typically presents unilaterally. 4

Monitoring for Disease Progression

• Patients with polyarticular hand OA are at increased risk for knee OA (OR 3.0) and hip OA (OR 3.25) and should be assessed accordingly. 1
• The concept of "generalized OA" indicates some individuals are at increased risk of multiple joint involvement. 1

Treatment Combinations to Avoid

• Combination of NSAIDs with salicylates is not recommended as aspirin increases naproxen excretion and data are inadequate to demonstrate additive benefit. 3
• The combination may result in higher frequency of adverse events than either product alone. 3

When to Consider Surgical Intervention

• Surgery should be considered for severe thumb base OA with marked pain and/or disability when conservative treatments have failed. 1
• Options include interposition arthroplasty, osteotomy, or arthrodesis for first CMC joint involvement. 1
• For fifth MCP joint arthritis that fails conservative management, arthroplasty may be considered, though this is typically reserved for more advanced disease. 5, 6