Diagnostic Considerations

The importance of recognizing hypertrophic osteoarthropathy (HOA) 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 lungs and heart.

Other disorders to consider in the differential diagnosis include acromegaly, thyroid acropachy, and scleromyxedema, syphilitic periostitis, osteopetrosis, and Paget disease. The disfigurements in facial and skeletal appearances have been confused with leprosy and syphilis, which are especially important considerations in some developing countries.

Inflammatory arthropathy may be incorrectly diagnosed in cases of malignant lung tumors, in which painful arthropathy can be the presenting feature of HOA. HOA is more likely when the following factors are present:

Pain that extends beyond the joint into the adjacent bone
Absence of rheumatoid factor
Noninflammatory synovial fluid

Acromegaly may be suggested in cases of exuberant skin hypertrophy and enlarged hands and feet.^[95] However, in acromegaly, bones in general are larger in the face, jaw (prognathism), skull, and limbs; this is very evident in a radiographic study in the absence of signs of periostosis.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 HOA include the following:

Spooning of nails secondary to iron deficiency anemia
Calcific deposits in distal digital pads of patients with scleroderma
Sarcoid involvement of the digit

Other diseases associated with periostitis should be included in the differential diagnosis. In HOA, the periostitis involves the distal diaphysis of long bones and metacarpal joints, while in other diseases, the involvement is as follows:

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, orbital
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 interleukin-11 - Clavicle, long bones
Osteomyelitis - Variable
Chronic leg ulcers - Tibia
Synovitis-acne-pustulosis-hyperostosis (SAPHO) syndrome - Variable

Various causes of unidigital clubbing include the following:

Aortic/subclavian aneurysm
Brachial plexus injury
Shoulder subluxation
Superior sulcus (Pancoast) tumor
Median nerve injury
Trauma
Maffucci syndrome
Gout, sarcoidosis
Severe herpetic whitlow
Hemodialysis

Localized clubbing, similar to unilateral digital clubbing, has been described in association with local vascular lesions such as aneurysms; arteriovenous fistulas; and venous abnormalities of the arm, axilla, and thoracic outlet.^{[61, 62]}

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

Workup

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Media Gallery

Clubbing associated with hypertrophic osteoarthropathy can be classified into 3 topographical groups (ie, symmetrical, unilateral, unidigital). This is symmetrical clubbing; it involves all the fingers.
Joint symptoms of hypertrophic osteoarthropathy range from mild to severe arthralgias that involve the metacarpal joints, wrists, elbows, knees, and ankles. The range of motion of affected joints may be slightly decreased. When effusions are present, they usually involve the large joints (eg, knees, ankles, wrists).
For hypertrophic osteoarthropathy diagnosis, 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.
In adulthood, 90% of generalized hypertropic osteoarthropathy cases are associated with an intrathoracic infectious or neoplastic condition.

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Author

Vishnuteja Devalla, MD Fellow, Department of Rheumatology, Dartmouth-Hitchcock Medical Center

Vishnuteja Devalla, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Nothing to disclose.

Coauthor(s)

Stephanie Danielle Mathew, DO Fellowship Program Director, Dartmouth-Hitchcock Medical Center

Stephanie Danielle Mathew, DO is a member of the following medical societies: American College of Physicians, American College of Rheumatology, American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Lawrence H Brent, MD Associate Professor of Medicine, Sidney Kimmel Medical College of 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 for the Advancement of Science, American Association of Immunologists, American College of Physicians, American College of Rheumatology

Disclosure: Stock ownership for: Johnson & Johnson.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Bryan L Martin, DO Associate Dean for Graduate Medical Education, Designated Institutional Official, Associate Medical Director, Director, Allergy Immunology Program, Professor of Medicine and Pediatrics, Ohio State University College of Medicine

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, American Osteopathic Association

Disclosure: Nothing to disclose.

Richa Dhawan, MD, CCD Associate Professor, Director of Osteoporosis Clinic, Center of Excellence for Arthritis and Rheumatology, Louisiana State University Health Science Center at Shreveport

Richa Dhawan, MD, CCD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American College of Rheumatology, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Mehwish Amir Khan, MD Fellow in Rheumatology, Louisiana State University Health Science Center at Shreveport

Mehwish Amir Khan, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.

Acknowledgements

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, FRCPC Professor of Medicine, Director of Rheumatology, Department of Medicine, Division of Rheumatology, McGill University Health Center (MUHC) and McGill University Faculty of Medicine; Director, The McGill Arthritis Center; Senior Physician, Shriner's Hospital for Crippled Children, Montreal; Leader, MSK Research Axis, MUHC Research Institute

Henri Andre Menard, MD, FRCPC 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.

Fahd Saeed, MD Rheumatology Fellow, Louisiana State University Health Sciences Center, Shreveport

Disclosure: Nothing to disclose.