Treatment of Wrist Bone Spurs
For wrist bone spurs (osteoarthritis), begin with education on joint protection and daily strengthening exercises, then add topical NSAIDs as first-line pharmacological treatment, reserving oral NSAIDs for inadequate response and surgery for structural deformity with treatment failure. 1, 2
Core Non-Pharmacological Treatment (Start Here for All Patients)
Education on joint protection techniques to avoid mechanical factors that accelerate joint damage, including proper wrist positioning during daily activities and avoiding repetitive gripping motions (strength of recommendation: 59-77) 1, 2
Structured daily home exercise program consisting of range-of-motion and strengthening exercises for the affected wrist, performed daily 1, 2
Heat application (paraffin wax or hot packs) for 15-20 minutes before exercise sessions to improve joint mobility (strength of recommendation: 59-77) 1, 2, 3
Assistive devices (jar openers, tap turners, built-up utensil handles) to perform activities without excessive joint stress 1, 3
Weight loss if overweight or obese, as excess weight increases mechanical stress on all joints 1
Pharmacological Treatment Algorithm
First-Line: Topical Agents (Preferred Over Systemic)
Topical NSAIDs (diclofenac gel, ibuprofen cream) applied to affected wrist 3-4 times daily—superior safety profile with effectiveness equal to oral NSAIDs (effect size 0.77, strength of recommendation: 75) 1, 2, 3
Topical capsaicin 0.025-0.075% applied as thin film 3-4 times daily—NNT of 3 for moderate pain relief (strength of recommendation: 75) 1, 2
Second-Line: Oral Analgesics
Acetaminophen up to 4g/day is the oral analgesic of first choice before NSAIDs (strength of recommendation: 87, with 92% expert consensus) 1, 2, 3
Oral NSAIDs only after topical NSAIDs and acetaminophen have failed—use lowest effective dose for shortest duration with mandatory cardiovascular and gastrointestinal risk stratification 1, 2, 3, 4
Critical caveat: In patients ≥75 years, never start oral NSAIDs without trying topical NSAIDs first due to superior safety profile 3
Risk assessment required: Never prescribe oral NSAIDs without assessing cardiovascular risk (history of MI, stroke, heart failure, hypertension) and gastrointestinal risk (prior ulcer, GI bleeding, concurrent anticoagulation) 1, 3
Reassess every 4-8 weeks—never continue oral NSAIDs indefinitely without evaluating necessity, efficacy, and emerging risk factors 3
Adjunctive Interventions for Specific Situations
Wrist splints or orthoses for symptom relief during painful flares or to prevent deformity progression (strength of recommendation: 67) 1, 2
Intra-articular corticosteroid injection for moderate to severe pain during inflammatory flares—particularly effective for specific joint involvement (strength of recommendation: 60) 1, 2
Surgical Referral Criteria
Consider surgery (interposition arthroplasty, osteotomy, or arthrodesis) for severe wrist osteoarthritis with structural deformity when conservative treatment has failed after 3-6 months (strength of recommendation: 68) 1, 2, 3, 5
Partial wrist fusion (Watson procedure) results in pain-free wrist in 80% of cases with 50% mobility preserved and stable results for at least 10 years 5
Complete denervation provides pain relief in almost 80% of cases while preserving motion and strength—safe option with no age limit that allows future procedures 5
Total wrist fusion has reliable outcomes for pain and strength with high satisfaction rates, particularly useful in revision cases 5
Common Pitfalls to Avoid
Do not overlook non-pharmacologic interventions—these form the foundation and should never be omitted even when medications are added 1, 3
Never use COX-2 inhibitors in patients with established cardiovascular disease 3
Do not prescribe glucosamine or chondroitin—insufficient evidence and not recommended 1
Avoid electroacupuncture—should not be used 1
Do not use conventional or biological disease-modifying antirheumatic drugs for wrist osteoarthritis 1