Osteoarthritis (OA) of the Hand

Background

• OA of the hand is a common degenerative joint disorder affecting the articular cartilage, subchondral bone, synovium, and surrounding joint structures of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and/or distal interphalangeal (DIP) joints, which often results in joint pain, stiffness, and functional limitations.
• Among all the joints that are affected by OA, the hand is 1 of the most commonly involved sites, along with the hip and knee.
• The exact cause of primary (idiopathic) hand OA is unknown, but it is likely multifactorial in nature, and related to the effects of aging. Causes of secondary hand OA may include prior joint changes, as well as metabolic and endocrine disorders.
• Risk factors for OA of the hand include modifiable risk factors, such as, obesity/overweight and occupational exposure.

Evaluation

• Suspect hand OA based on the history and physical exam findings, including:
  • pain (typically related to activity, often worsening throughout the day)
  • stiffness (typically worse in the morning, often improving within 60 minutes of waking)
  • restricted hand movement with functional limitations (due to decreased grip/pinch strength), such as, difficulty opening a bottle
• Imaging is generally not required for the routine diagnosis of hand OA, as the diagnosis is typically made clinically based on hallmark signs and symptoms.
  • In patients with atypical clinical presentation, imaging may be used to confirm the diagnosis, and/or assist in determining an alternative or additional diagnosis.
  • If needed, a plain x-ray should be the initial imaging modality.
  • Advanced imaging, such as, an ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT), is rarely needed for the diagnosis of hand OA, but it can assist in the evaluation of other pathology.

Management

• The primary goals of management are to preserve hand function and decrease pain.
• Nonoperative management is generally the first-line treatment in all patients with hand OA.
  • Nonpharmacologic strategies:
    • Patients should participate in exercise to improve strength and function (Strong recommendation); however, no specific type of exercise is recommended over another.
    • Patients should participate in education and self-management programs involving education about the course of the disease, as well as strategies for joint protection and weight management when indicated (Strong recommendation).
    • Consider the use of physical supports, such as, splints or pressure gloves (Weak recommendation).
    • Therapeutic modalities, such as, paraffin and ultrasound, may also be considered (Weak recommendation).
  • Pharmacologic strategies:
    • Topical analgesics are typically preferred over systemic treatments due to safety concerns; topical nonsteroidal anti-inflammatory drugs (NSAIDs) are the preferred first-line pharmacological topical treatment (Strong recommendation).
    • Advise the use of oral analgesics in patients with symptoms refractory to topical treatments (Strong recommendation).
    • Other pharmacologic strategies that may be considered include:
      • Use of intra-articular corticosteroid injection may be considered, particularly in patients with painful interphalangeal joints (Weak recommendation), but it should not be used routinely (Strong recommendation).
      • Opioid analgesics (particularly tramadol) may be considered in patients with an inadequate response to all other therapies, following an individualized assessment of the risks and benefits (Weak recommendation).
  • Consider the use of dietary and herbal therapies, such as:
    • glucosamine
    • chondroitin (Weak recommendation)
    • GCSB-5
• Operative management is generally indicated in patients with persistent pain, deformity, instability, or stiffness despite nonoperative management (Weak recommendation); options include arthroplasty and arthrodesis (joint fusion).
• Consider individualized long-term follow-up of patients with hand OA to the patient’s needs (Weak recommendation).
  • Routine use of follow-up imaging is not recommended.
  • Imaging is recommended in patients presenting with sudden, rapid worsening of symptoms or change in clinical features, to determine the cause.