What is the best management for a patient with mild degenerative changes in the carpometacarpal joint of the thumb, no acute fracture, and normal soft tissue?

Management of Mild Thumb Carpometacarpal Joint Osteoarthritis

For a patient with mild degenerative changes in the thumb carpometacarpal joint without acute fracture, initiate a multimodal conservative approach starting with patient education, hand exercises, and a custom-fitted thumb orthosis for long-term use (at least 3 months), combined with topical NSAIDs as first-line pharmacological treatment. 1, 2

Initial Non-Pharmacological Management

Patient Education and Self-Management

• Provide education on ergonomic principles, pacing of activities, and use of assistive devices to all patients with thumb base osteoarthritis 1, 2
• This education should be delivered by a specialized health professional such as an occupational or physical therapist 1
• The goal is to optimize hand function and maximize quality of life, not merely achieve symptom control 1

Exercise Prescription

• Prescribe hand exercises targeting joint mobility, muscle strength, and thumb base stability for every patient 1
• Exercise regimens for the first carpometacarpal joint differ from those for interphalangeal joints and should be specifically tailored 1
• Exercises provide small but beneficial effects on pain, function, joint stiffness, and grip strength, though benefits are not sustained when patients stop exercising 1
• Apply heat (paraffin wax or hot packs) before exercise sessions for symptomatic relief 2

Orthosis Management

• Prescribe a custom-fitted thumb orthosis for long-term use (minimum 3 months) as this provides pain relief and functional improvement 1, 2
• Custom-made orthoses fitted by a specialized health professional improve compliance and long-term use 1
• Evidence supports either a custom-made thermoplast long orthosis worn during activities of daily living, or a custom-made neoprene long orthosis worn at night 1
• Short-term orthosis use (less than 3 months) does not show benefit 1

Pharmacological Treatment Algorithm

First-Line: Topical NSAIDs

• Topical NSAIDs (specifically topical diclofenac) are the first pharmacological treatment of choice due to their favorable safety profile compared to oral analgesics 1, 2
• Topical treatments are preferred over systemic treatments for safety reasons 1

Second-Line: Oral Analgesics

• If topical NSAIDs provide inadequate relief, consider acetaminophen up to 4g/day as the preferred long-term oral analgesic 2
• Oral NSAIDs (such as ibuprofen 400mg every 4-6 hours) should be used at the lowest effective dose for the shortest duration if acetaminophen fails 1, 2
• Add gastroprotective agents or use COX-2 inhibitors for patients with GI risk factors 2
• Avoid COX-2 inhibitors in patients with cardiovascular risk 2

Alternative Pharmacological Option

• Chondroitin sulfate may be used for pain relief and improvement in functioning, though this has lower evidence support 1

When to Consider Invasive Treatment

Intra-articular Corticosteroid Injections

• Consider corticosteroid injection when oral analgesics and topical treatments provide inadequate relief 2
• Injections are effective for painful flares in trapeziometacarpal joint osteoarthritis 1, 2
• This should be considered when pain significantly limits activities of daily living 2

Surgical Referral Criteria

• Refer to a hand surgeon when conservative treatments (including corticosteroid injections) have failed 2, 3
• Refer when the patient has marked pain and/or disability limiting activities of daily living 2, 3
• Surgical options include trapeziectomy for thumb base OA 1, 3

Critical Pitfalls to Avoid

• Do NOT offer platelet-rich plasma (PRP) injections for thumb CMC osteoarthritis, as guidelines explicitly recommend against this due to insufficient evidence 4
• Do NOT use intra-articular glucocorticoid injections routinely in hand OA; they may only be considered for painful interphalangeal joints, not as first-line for CMC joint 1
• Do NOT treat with conventional or biological disease-modifying antirheumatic drugs 1
• Do NOT prescribe short-term orthosis use (less than 3 months), as no benefit is evident 1
• Ensure stepwise progression through non-pharmacological, pharmacological, and invasive non-surgical options before considering surgery 2, 4

Follow-Up Considerations

• Long-term follow-up should be adapted to the patient's individual needs 1
• Monitor for progression of symptoms and functional limitations 1
• Reassess treatment efficacy at regular intervals, particularly orthosis compliance and exercise adherence 1