Msk Dermatology · Year 2 · from Msk Dermatology

Case 2: Hand Osteoarthritis with First Carpometacarpal Involvement

Patient Presentation

Demographics: 58-year-old woman

Chief Complaint: "I'm having trouble opening jars and my thumbs hurt constantly."

History of Present Illness: The patient reports progressive pain and stiffness in both hands over the past three years, most pronounced at the base of both thumbs and in the finger joints. She notices bony bumps on her fingers that have slowly enlarged. She experiences difficulty with pinching and gripping activities, particularly opening jars, turning keys, and writing. Morning stiffness lasts approximately 10-15 minutes. She works as a seamstress and is concerned about her ability to continue her profession.

Past Medical History:

• Hypothyroidism
• Osteoporosis
• Postmenopausal (menopause at age 52)

Medications:

• Levothyroxine 75 mcg daily
• Alendronate 70 mg weekly
• Calcium and vitamin D supplements

Family History:

• Mother and maternal grandmother both had "knotty fingers"

Physical Examination

• Vital Signs: BP 128/76 mmHg, HR 72 bpm, BMI 24 kg/m2
• Hands:
• Bilateral Heberden nodes (DIP joints) with bony enlargement
• Bilateral Bouchard nodes (PIP joints), less prominent
• Squared appearance of bilateral thumb bases (first CMC joints)
• Tenderness at bilateral first CMC joints with positive grind test
• Crepitus with thumb range of motion
• No synovitis or warmth
• Reduced grip and pinch strength bilaterally
• MCP joints normal without swelling or tenderness

Workup and Results

Laboratory Studies:

Imaging:

• Hand radiographs (AP and oblique):
• DIP and PIP joint space narrowing with osteophytes bilaterally
• Subchondral sclerosis at affected joints
• First CMC joint narrowing with radial subluxation bilaterally
• No erosions
• MCP joints preserved

Clinical Image

Clinical photograph demonstrating Heberden nodes (bony enlargement at the distal interphalangeal joints) characteristic of nodal hand osteoarthritis. Source: Wikimedia Commons, CC BY 3.0.

Diagnosis

Nodal Hand Osteoarthritis with First Carpometacarpal (Thumb Base) Osteoarthritis

Supporting Features:

• Typical joint distribution (DIP, PIP, first CMC) with sparing of MCP joints
• Heberden and Bouchard nodes
• Strong family history consistent with genetic predisposition
• Postmenopausal woman (higher risk)
• Normal inflammatory markers excluding inflammatory arthritis
• Radiographic findings consistent with osteoarthritis without erosions

Treatment Plan

Non-Pharmacologic Management:

1. Hand therapy: Strengthening exercises, joint protection education
2. Thumb spica splint: For first CMC support during aggravating activities
3. Adaptive equipment: Jar openers, ergonomic tools, built-up handles
4. Paraffin wax baths: For pain and stiffness relief
5. Activity modification: Avoid prolonged pinching, adjust work techniques

Pharmacologic Management:

1. Topical diclofenac gel: Applied to hands three times daily (hands are superficial and respond well to topical therapy)
2. Acetaminophen: 650 mg as needed for flares
3. Intra-articular corticosteroid injection: Consider for first CMC joints if refractory

Follow-up:

• Reassess in 6-8 weeks
• Occupational therapy referral for work modifications
• If severe first CMC involvement progresses, surgical options include trapeziectomy or arthroplasty

Teaching Points

1. Nodal osteoarthritis: Strongly hereditary form affecting DIP (Heberden nodes) and PIP (Bouchard nodes) joints; common in postmenopausal women
2. First CMC osteoarthritis: Squared thumb base appearance; grind test (axial compression with rotation) elicits pain and crepitus
3. MCP sparing: Involvement of MCP joints suggests rheumatoid arthritis or other inflammatory arthropathy rather than primary osteoarthritis
4. Topical NSAIDs: Particularly effective for hand osteoarthritis given superficial joint location; reduced systemic side effects compared to oral NSAIDs
5. Erosive osteoarthritis: A more inflammatory and destructive variant with central erosions and "gull wing" or "saw tooth" deformities may occur in some patients

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