Hypertrophic Osteoarthropathy (incl. Pachydermoperiostosis)

The combination of symmetric periosteal new bone along the long bones, finger clubbing and limb pain is hypertrophic osteoarthropathy, which is the triad of clubbing, periostosis and arthralgia. The crucial point is that, in an adult with new-onset disease, this is most likely the secondary form, which is a paraneoplastic and systemic marker - classically of intrathoracic malignancy such as non-small-cell lung cancer or mesothelioma, and of suppurative lung disease such as bronchiectasis or a lung abscess, and also of cyanotic heart disease, inflammatory bowel disease and liver disease. So the most important thing I must do is not treat this as an isolated bone problem but search for the underlying cause, focusing on the chest - history, examination, chest radiograph and CT - because treating the underlying tumour or lung disease often improves or resolves the HOA. I would confirm the periostosis on radiographs, where it is symmetric along the diaphyses and metaphyses, and a bone scan would show symmetric tramline cortical uptake, which is sensitive for early disease; the Schamroth sign screens for the clubbing. I would distinguish it from the rare primary form, pachydermoperiostosis, which is a genetic prostaglandin-pathway disorder presenting in young men with additional skin changes of pachyderma and cutis verticis gyrata. Management is to treat the underlying cause in secondary disease and to relieve symptoms with NSAIDs, with bisphosphonates or prostaglandin-pathway agents as adjuncts.