Classification of HOA. | MSK = musculoskeletal. | Yap, F. Y., Skalski, M. R., Patel, D. B., Schein, A. J., White, E. A., Tomasian, A., … Matcuk, G. R. (2016). Hypertrophic Osteoarthropathy: Clinical and Imaging Features. RadioGraphics, 37(1), 157–195. https://doi.org/10.1148/rg.2017160052
Pathophysiology
Illustrations demonstrating the hypothesized mechanisms underlying the pathogenesis of HOA in congenital heart disease with right-to-left shunt (a) due to failure to fragment platelet precursors within the pulmonary circulation or with pleural or pulmonary disease (b) resulting in the release of growth factors and trophic effects on capillary beds, in both cases promoting vascularity and stimulation of fibroblasts and osteoblasts, and leading to periostitis and finger clubbing. | Yap, F. Y., Skalski, M. R., Patel, D. B., Schein, A. J., White, E. A., Tomasian, A., … Matcuk, G. R. (2016). Hypertrophic Osteoarthropathy: Clinical and Imaging Features. RadioGraphics, 37(1), 157–195. https://doi.org/10.1148/rg.2017160052
Yap, F. Y., Skalski, M. R., Patel, D. B., Schein, A. J., White, E. A., Tomasian, A., … Matcuk, G. R. (2016). Hypertrophic Osteoarthropathy: Clinical and Imaging Features. RadioGraphics, 37(1), 157–195. https://doi.org/10.1148/rg.2017160052
Clinical features
Primary HOA:
Coarse facial features
Furrowing and oiliness of skin of face
Digital clubbing
Cutis verticis gyrata: Marked furrowing of scalp
Radiographic periostitis of distal long bones
Secondary HOA:
Rapidly evolving joint pain and swelling of acute onset.
Digital clubbing “Hippocratic fingers”
Periostosis of tubular bones
Synovial effusions
Photograph showing digital clubbing of hand. | Nayak, H. K., Rajkumar, V. D., Kumar, N., & Kar, P. (2012). Primary hypertrophic osteoarthropathy (incomplete form) in young adults: a case report and review of literature. BMJ case reports, 2012, bcr2012007745. doi:10.1136/bcr-2012-007745
Diagnosis
Clinical diagnosis:
Methods to diagnose digital clubbing at physical examination include the hyponychial angle (angle abc 192° with clubbing, right), Lovibond or profile angle (angle abd 180° for clubbing, right), phalangeal depth ratio (distal phalangeal depth [DPD]/interphalangeal depth [IPD] ratio 1 for clubbing, right), Schamroth sign (loss of normal diamond-shaped window between nailbeds when nails are placed together), and digital index (sum of nail bed circumference [NB]/distal interphalangeal circumference [DIP] ratios for all fingers, >10 for clubbing). | Yap, F. Y., Skalski, M. R., Patel, D. B., Schein, A. J., White, E. A., Tomasian, A., … Matcuk, G. R. (2016). Hypertrophic Osteoarthropathy: Clinical and Imaging Features. RadioGraphics, 37(1), 157–195. https://doi.org/10.1148/rg.2017160052
Imaging:
X-ray of the left femur: periosteal thickening at the regions of the arrows | Kumari, P., Yeung, P., Medani, A., & Kiani, A. N. (2018). Hypertrophic pulmonary osteoarthropathy: an unusual presentation. Rheumatology advances in practice, 2(1), rky009. doi:10.1093/rap/rky009
Fluid-sensitive MRI sequence: oedema-like signal along the medial femur, including along the periosteum, with areas of periosteal thickening along the medial left femur (white arrows) | Kumari, P., Yeung, P., Medani, A., & Kiani, A. N. (2018). Hypertrophic pulmonary osteoarthropathy: an unusual presentation. Rheumatology advances in practice, 2(1), rky009. doi:10.1093/rap/rky009
Bilateral femur uptake of 99mTc-hydroxymethylene diphosphonate on bone scintigraphy. | Qian, X., & Qin, J. (2014). Hypertrophic pulmonary osteoarthropathy with primary lung cancer. Oncology letters, 7(6), 2079–2082. doi:10.3892/ol.2014.2022
Management
Primary HOA:
Polyarthritis and bone pain: NSAIDs, corticosteroids, infliximab
