How should swelling and pain be managed in a patient with severe arthritis of the thumb carpometacarpal (CMC) joint, trapeziometacarpal joint, and radiocarpal joint, and moderate distal radioulnar joint (DRUJ) degeneration?

Management of Multi-Joint Wrist and Thumb Arthritis

You need urgent surgical referral for definitive treatment with radioscapholunate arthrodesis, distal scaphoidectomy, and simple trapeziectomy—your severe multi-joint disease has progressed beyond the point where conservative management is effective. 1

Why Surgery Is Indicated Now

• When severe arthritis involves multiple joints (thumb CMC, triscaphe, radiocarpal) with moderate DRUJ degeneration, current guidelines indicate that conservative measures have already failed and surgery is warranted. 1

• The presence of severe, multi-joint disease distinguishes your case from isolated thumb CMC osteoarthritis, where stepwise conservative care would be appropriate. 1

• Do not delay surgical referral—patients with your pattern of disease have typically progressed beyond conservative management effectiveness. 1

Bridging Symptom Management Until Surgery

While awaiting surgical evaluation and procedure, symptom control should follow this hierarchy:

First-Line Pharmacological Management

• Topical NSAIDs are the preferred initial pharmacological treatment for swelling and pain, offering efficacy with minimal systemic side effects. 2

• Oral acetaminophen (up to 4g/day) should be your first oral analgesic choice due to its favorable safety profile. 2

• Oral NSAIDs (such as naproxen) should be used at the lowest effective dose and shortest duration if acetaminophen provides inadequate relief. 2, 3

  • Naproxen reduces joint swelling and pain, with onset of relief beginning within 1 hour and lasting up to 12 hours. 3
  • Use gastroprotective agents if you have increased gastrointestinal risk, or consider selective COX-2 inhibitors (though these are contraindicated with cardiovascular risk). 2

Physical Modalities for Swelling Control

• Ice application immediately and regularly helps control acute inflammation and swelling. 4

• Heat application (paraffin wax or hot packs) may provide symptomatic relief, especially when applied before any gentle range-of-motion activities. 2

• Activity modification to avoid adverse mechanical stress on the affected joints is essential. 2

Invasive Non-Surgical Options

• Intra-articular corticosteroid injections are effective for painful flares and should be considered when the above measures provide inadequate relief. 2

• These injections serve as a bridge to surgery but their failure further confirms the need for surgical intervention. 5, 2

The Definitive Surgical Plan

Recommended Procedures

• Simple trapeziectomy (without ligament reconstruction or tendon interposition) is the recommended technique for your severe thumb CMC arthritis. 1

  • Level I evidence from Cochrane review shows that adding ligament reconstruction and tendon interposition does not improve pain relief (effect size = -0.17) or functional outcomes (effect size = 0.03). 1
  • Combined procedures have a 2.12-fold higher complication rate including tendon rupture, scar tenderness, neurological injury, and complex regional pain syndrome. 1

• Radioscapholunate arthrodesis with distal scaphoidectomy addresses your severe triscaphe and radiocarpal joint disease. 1

Surgical Staging Approach

• A staged approach is advisable given your multi-joint involvement. 1

• First stage should include radioscapholunate arthrodesis with distal scaphoidectomy plus thumb CMC arthroplasty (trapeziectomy). 1

• DRUJ arthroplasty may be performed either concurrently or as a second stage, depending on your DRUJ symptom severity and overall surgical complexity. 1

Critical Pitfalls to Avoid

• Do not pursue ligament reconstruction and tendon interposition with your trapeziectomy—this increases complications without improving outcomes. 1

• Do not continue prolonged conservative management—the stepwise algorithm applies to isolated thumb CMC arthritis, not severe multi-joint disease like yours. 1

• Do not use aspirin in combination with naproxen, as aspirin increases naproxen excretion and the combination results in higher adverse event frequency without additional benefit. 3