eMedicine Specialties > Rheumatology > Metabolic and Bone Disease

Hypertrophic Osteoarthropathy: Differential Diagnoses & Workup

Author: Richa Dhawan, MD, Faculty, Center of Excellence for Arthritis and Rheumatology, Louisiana State University Health Science Center at Shreveport
Coauthor(s): Mohammed Mubashir Ahmed, MD, Associate Professor, Department of Medicine, Division of Rheumatology, University of Toledo College of Medicine; Henri-Andre Menard, MD, Professor of Medicine, Director of Rheumatology, Department of Medicine, Division of Rheumatology, McGill University Health Center and McGill University; Director, The McGill Arthritis Center; Senior Physician, Shriner's Hospital for Crippled Children, Montreal
Contributor Information and Disclosures

Updated: Nov 7, 2008

Differential Diagnoses

Other Problems to Be Considered

Inflammatory arthropathy may be incorrectly diagnosed in cases of malignant lung tumors, in which painful arthropathy can be the presenting feature of hypertrophic osteoarthropathy (HOA). Hypertrophic osteoarthropathy is more likely when the following factors are present: pain that extends beyond the joint into the adjacent bone, an absence of rheumatoid factor, and noninflammatory synovial fluid.

Acromegaly may be suggested in cases of exuberant skin hypertrophy and enlarged hands and feet. Normal growth hormone levels and the absence of both prognathism and enlarged sella turcica exclude acromegaly.

Fingertip changes due to other conditions that may be confused with hypertrophic osteoarthropathy include spooning of nails secondary to iron deficiency anemia, calcific deposits in distal digital pads of patients with scleroderma, and sarcoid involvement of the digit.

Diseases associated with periostitis with predominant location of periostitis should be included in the differential diagnoses, as follows:

  • Hypertrophic osteoarthropathy - Distal diaphysis of long bones and metacarpal joints
  • Psoriatic onycho-pachydermo periostitis - Terminal phalanx
  • Psoriatic arthritis - Phalanges of fingers and toes
  • Reactive arthritis - Phalanges of fingers and toes
  • Athletic overuse (running, jumping) - Upper and lower extremities
  • Ossifying fasciitis - Variable
  • Periostitis ossificans - Variable
  • Polyarteritis nodosa - Lower extremities
  • Systemic lupus erythematosus - Variable
  • Facial infections - Mandible, orbita
  • Florid reactive periostitis - Phalanges of hands and feet
  • Osteoblastoma - Variable
  • Bizarre parosteal osteochondromatous proliferation (Nora tumor) - Bones of the hands and feet
  • Chondrosarcoma - Variable
  • Treatment with IL-11 - Clavicle, long bones
  • Osteomyelitis - Variable
  • Chronic leg ulcers - Tibia
  • Synovitis-acne-pustulosis-hyperostosis (SAPHO) syndrome - Variable

Pretibial edema may be due to thrombophlebitis, venous stasis, or pretibial myxedema and may mimic periostosis.

The importance of recognizing hypertrophic osteoarthropathy cannot be overstated. A previously healthy individual with any manifestation of the syndrome should undergo a thorough evaluation for an underlying illness. Direct special attention toward the chest.

Workup

Laboratory Studies

  • The erythrocyte sedimentation rate may be elevated in persons with pachydermoperiostosis and is often elevated in those with secondary hypertrophic osteoarthropathy (HOA).8
  • Serum alkaline phosphatase levels may be elevated secondary to periosteal new bone formation.8
  • If an effusion is present, the synovial fluid is noninflammatory (cell count <500/µL), with a predominantly lymphocytic and monocytic infiltrate.14,16

Imaging Studies

  • Plain radiographs show 2 types of changes, bone formation with hypertrophy and bone dissolution with acroosteolysis.11
    • Periosteal thickening occurs along the shafts of long and short bones, initially appearing in the distal diaphyseal regions of the long bones. Periosteal changes are seen as a continuous thin line of sclerotic new bone separated from the cortex by a radiolucent space. Over time, the periosteal new bone thickens and fuses with the cortex, and the process extends proximally to the diaphysis and metaphysis. These changes are most commonly observed in the tibia, radius, ulna, fibula, and femur. Primary hypertrophic osteoarthropathy is distinguished by more exuberant periosteal new bone formation that extends to the epiphyseal regions.8
    • Acroosteolysis may be seen in the distal tufts in patients with long-standing hypertrophic osteoarthropathy.
  • Radionuclide bone scan using technetium Tc 99m polyphosphate shows increased uptake of the tracer in the periosteum, often appearing pericortical and linear in nature. These findings can be present even when findings from plain radiographs are doubtful. The clubbed digits may also show increased uptake in early passage flow studies (see Images 1-3).8,31
  • Angiography findings may demonstrate hypervascularization of the finger pads.44,13

Other Tests

  • An evaluation for the primary condition is warranted in patients with possible secondary hypertrophic osteoarthropathy; for example, search for an intrathoracic malignancy or infection.

More on Hypertrophic Osteoarthropathy

Overview: Hypertrophic Osteoarthropathy
Differential Diagnoses & Workup: Hypertrophic Osteoarthropathy
Treatment & Medication: Hypertrophic Osteoarthropathy
Follow-up: Hypertrophic Osteoarthropathy
Multimedia: Hypertrophic Osteoarthropathy
References
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Further Reading

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Keywords

hypertrophic osteoarthropathy, primary hypertrophic osteoarthropathy, primary HOA, HOA, secondary HOA clubbing, Hippocratic fingers, clubbed digits, pachydermoperiostosis, acroosteolysis, Touraine-Solente-Golé syndrome, Goldbloom's syndrome, Goldbloom syndrome, Pierre Marie-Bamberger's disease, Pierre Marie-Bamberger disease, osteoarthropathie hypertrophiante pneumique, hypertrophic pulmonary osteoarthropathy, HPOA, acropachy, hyperhidrosis, digital clubbing, periostosis, intrathoracic malignancy, intrathoracic infection, cyanotic cardiac disease, cyanotic heart disease, congenital clubbing, familial clubbing, osteosarcoma, thyroid acropachy, Crohn disease, Crohn's disease, polyposis, thymoma, achalasia, Graves disease, Graves' disease, thalassemia, POEMS syndrome

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Contributor Information and Disclosures

Author

Richa Dhawan, MD, Faculty, Center of Excellence for Arthritis and Rheumatology, Louisiana State University Health Science Center at Shreveport
Richa Dhawan, MD is a member of the following medical societies: American Association of Physicians of Indian Origin, American College of Physicians-American Society of Internal Medicine, and American College of Rheumatology
Disclosure: Nothing to disclose.

Coauthor(s)

Mohammed Mubashir Ahmed, MD, Associate Professor, Department of Medicine, Division of Rheumatology, University of Toledo College of Medicine
Mohammed Mubashir Ahmed, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Federation for Medical Research
Disclosure: Nothing to disclose.

Henri-Andre Menard, MD, Professor of Medicine, Director of Rheumatology, Department of Medicine, Division of Rheumatology, McGill University Health Center and McGill University; Director, The McGill Arthritis Center; Senior Physician, Shriner's Hospital for Crippled Children, Montreal
Henri-Andre Menard, MD is a member of the following medical societies: American College of Rheumatology, Canadian Medical Association, Canadian Rheumatology Association, and Quebec Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Bryan L Martin, DO, Chief, Allergy Immunology Department, Walter Reed Army Medical Center; Associate Professor of Medicine and Pediatrics, Uniformed Services University of the Health Sciences; United States Army Consultant in Allergy Immunology and Immunizations
Bryan L Martin, DO is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Osteopathic Internists, American College of Physicians, American Medical Association, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Lawrence H Brent, MD, Associate Professor of Medicine, Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Lawrence H Brent, MD is a member of the following medical societies: American Association of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; Merck, Amgen, Biogen, Zimmer, Wyeth, Johnson&Johnson, Stryker, Medtronic, Zimmer.Abbott,  Ownership interest Other; West Penn Allegheny Health System Consulting fee Consulting; Alpharma Honoraria Consulting; Proctor&Gamble Grant/research funds Independent contractor

 
 
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