Hand & Wrist OA

Patients describe gradually progressive pain, stiffness, and reduced grip strength. Morning stiffness is brief (under 30 minutes), distinguishing OA from inflammatory arthritis. Aggravators include cold weather, gripping tasks (jars, keys, doorknobs), and prolonged writing. The thumb base ache of CMC1 OA is often the dominant symptom and may radiate into the thenar eminence.

The distribution is highly characteristic: DIP joints with Heberden's nodes, PIPs with Bouchard's nodes, and the thumb CMC1 with squaring at the base. MCP joints are spared. This contrasts sharply with rheumatoid arthritis, which favours the MCPs, PIPs, and wrist and spares the DIPs, with prolonged morning stiffness over an hour, soft fusiform swelling, and systemic features.

Examination:

• •DIP and PIP: bony enlargement, deformity (mallet, swan-neck, boutonniere in advanced disease), reduced ROM, crepitus
• •CMC1: tender thumb base, squaring (osteophyte and subluxation), reduced palmar abduction. Grind test - axial load with rotation at the CMC1 - reproduces pain (sensitive and specific). The Watson scaphoid shift test is positive in scapholunate-driven wrist OA
• •Grip strength reduction (Jamar dynamometer) and pinch strength (key-pinch gauge) document functional impairment
• •Look for synovitis, warmth, and skin changes that suggest erosive OA or inflammatory arthropathy

Functional impact (buttons, zips, opening jars, writing) is more important than radiographic severity for management decisions. Differentials include rheumatoid arthritis, psoriatic arthritis, gout (tophi at DIPs), and de Quervain's (radial wrist, distinguishes from CMC1 by Finkelstein's test).

OA is a clinical diagnosis (NICE NG226 confirms this). Imaging is reserved for diagnostic uncertainty, atypical features, or pre-operative planning.

Plain radiographs (PA and lateral hand, dedicated CMC1 view) show the classic OA tetrad:

• •Joint-space narrowing
• •Subchondral sclerosis
• •Subchondral cysts
• •Osteophytes

DIP and PIP OA show marginal osteophytes (Heberden's and Bouchard's). Erosive OA shows central "gull-wing" subchondral erosions in addition. CMC1 OA: joint-space narrowing, dorsoradial subluxation of the metacarpal base, squaring, and scaphotrapezial involvement in pantrapezial disease (Eaton-Littler stage IV). MRI is not indicated routinely; it is reserved for assessing scapholunate or TFCC integrity in atypical wrist OA, or pre-operative planning. Ultrasound can detect early synovitis when an inflammatory cause is in the differential.

Routine bloods are not needed to diagnose OA but are reasonable when inflammatory disease is on the differential: FBC, CRP, ESR, RhF, anti-CCP, urate, ferritin (haemochromatosis if MCP OA pattern), and psoriasis screen as clinically indicated.

Management follows NICE NG226 (2022): a stepped pathway of patient-centred conservative measures first, with referral and intervention for failed conservative care.

First-line (all patients):

• •Education, joint protection advice, weight where appropriate, structured exercise and grip strengthening
• •Topical NSAIDs (e.g. ibuprofen, diclofenac gel) for hand and CMC1 OA - first pharmacological choice per NICE NG226 (oral NSAIDs are second-line when topicals are insufficient)
• •Splinting: neoprene thumb spica or rigid thumb spica for CMC1 OA, particularly for nocturnal symptoms or task-specific use
• •Simple analgesia (paracetamol) and oral NSAIDs as second-line short courses

Second-line: intra-articular corticosteroid injection.

• •CMC1 (typically methylprednisolone 20-40 mg with 1% lidocaine, ultrasound-guided) provides short-term relief in selected patients. Avoid repeated injections (NICE recommends short-term use only)
• •DIP and PIP injections may help focal flare; risk of skin atrophy is higher in small joints

Third-line (failed conservative): refer to hand surgery.

• •CMC1 OA surgical options: trapeziectomy (gold standard in the UK), with or without ligament reconstruction and tendon interposition (LRTI). Equivalent long-term outcomes between simple trapeziectomy and trapeziectomy plus LRTI in the largest UK trials. Joint replacement is offered in selected patients
• •DIP arthrodesis (fusion) for painful end-stage DIP OA where conservative measures fail
• •PIP options: arthrodesis (ulnar two fingers, for function) or arthroplasty (radial two fingers, to preserve motion)
• •Wrist OA: pancarpal arthrodesis, four-corner fusion, or proximal row carpectomy depending on pattern

Referral pathway: refer to hand surgery for surgical opinion when conservative measures fail (6-12 months trial), function is significantly limited, or for advanced deformity. Avoid premature surgical referral - most patients are managed satisfactorily with conservative measures.

Hand therapy is central to OA management at every stage.

Conservative pathway: hand-therapy-led exercise programme including range-of-movement exercises, gentle grip and pinch strengthening, and joint protection advice (using larger joints for tasks, avoiding sustained gripping, ergonomic adaptations). Custom-fitted splints for CMC1 OA (rigid for night-time, soft neoprene for daytime task use). Patient education on long-term self-management is foundational - NICE NG226 places this above pharmacological intervention.

Post-injection: avoid heavy gripping 24-48 hours; resume usual activity afterwards. Recurrent flare warrants therapy reassessment before re-injection.

Post-operative (trapeziectomy):

• •Weeks 0-2: bulky dressing then thumb spica plaster cast; finger and IP-joint ROM encouraged from day 1
• •Weeks 2-4: removable thumb spica splint; gentle thumb ROM exercises begin under hand therapy supervision
• •Weeks 4-8: progressive thumb opposition, strengthening, scar massage
• •Weeks 8-12: return to work and most ADLs; manual workers may need longer
• •Months 3-12: ongoing improvement in pinch strength and pain; final outcomes assessed at 1 year

Post-DIP arthrodesis: K-wire or screw-dependent splinting 6-8 weeks until bony union; full return to function at 12 weeks.

Persistent pain or deformity progression beyond 12 months post-operatively warrants reassessment.

• •NICE NG226 (2022) - UK foundation guideline: clinical diagnosis; topical NSAIDs as first-line pharmacological treatment for hand OA; short-term steroid injection; refer when conservative measures fail or function is significantly impaired.
• •NICE CKS Osteoarthritis - Practical primary-care framework aligned with NG226: education, exercise, weight where relevant, then stepped analgesia.
• •Eaton-Littler classification (1973) - Four-stage UK and international framework for CMC1 OA, guiding operative decisions and reflecting subluxation, joint-space loss, and pantrapezial involvement.
• •Davis et al. (1997, 2009) - UK randomised data: simple trapeziectomy gives equivalent long-term pain and function outcomes to trapeziectomy plus ligament reconstruction and tendon interposition; simpler surgery favoured in UK practice.
• •Kloppenburg et al. (HOPE trial, 2018; FOCUS trial, 2019) - Established that systemic disease-modifying anti-rheumatic drugs (hydroxychloroquine, methotrexate) do not improve hand OA outcomes, supporting the symptomatic-only treatment approach.

• •Classic OA distribution: DIPs (Heberden's), PIPs (Bouchard's), and CMC1 (thumb base squaring). MCP-joint OA is NOT primary hand OA - look for haemochromatosis, CPPD, or inflammatory arthropathy.
• •NICE NG226 makes topical NSAIDs the first-line pharmacological treatment for hand OA, ahead of oral NSAIDs and paracetamol.
• •Grind test (axial compression and rotation at CMC1) is the bedside discriminator for CMC1 OA; positive Watson scaphoid shift suggests scapholunate-driven wrist OA.
• •Erosive OA shows central "gull-wing" subchondral erosions on PA radiographs of the DIPs and PIPs, distinct from psoriatic mutilans (pencil-in-cup) and rheumatoid (marginal erosions).
• •Trapeziectomy is the UK gold-standard surgical procedure for end-stage CMC1 OA. Trapeziectomy alone is equivalent to trapeziectomy plus LRTI on long-term outcomes; simpler surgery is favoured.
• •Morning stiffness over an hour, MCP/wrist involvement, soft fusiform swelling, warmth, and raised inflammatory markers are inflammatory features. Reassess and refer to rheumatology - they are not OA.