[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Conditions](https://durgical.com/en/conditions/) › Hypertrophic osteoarthropathy and digital clubbing [Conditions](https://durgical.com/en/conditions/) · [Rheumatology](https://durgical.com/en/conditions/) # Hypertrophic osteoarthropathy and digital clubbing Bulbous swelling of the fingertips and new bone along the long bones, often caused by lung cancer or chronic lung or heart disease. Updated 2026-11-01 ## Structures involved Tap one to see what it is and open it in 3D. - [Distal phalanx, index finger](https://durgical.com/en/anatomy/distal-phalanx-of-the-index-finger/) - [Radius](https://durgical.com/en/anatomy/radius/) - [Tibia](https://durgical.com/en/anatomy/tibia/) - [Distal phalanx, thumb](https://durgical.com/en/anatomy/distal-phalanx-of-the-thumb/) - [Distal phalanx, middle finger](https://durgical.com/en/anatomy/distal-phalanx-of-the-middle-finger/) - [Ulna](https://durgical.com/en/anatomy/ulna/) - [Fibula](https://durgical.com/en/anatomy/fibula/) - [Femur](https://durgical.com/en/anatomy/femur/) - [Wrist capsule](https://durgical.com/en/anatomy/wrist-joint-capsule/) - [Joint capsule](https://durgical.com/en/anatomy/articular-capsule-of-knee-joint/) ## Why it happens - [Paraneoplastic syndromes: the table to know](https://durgical.com/en/general-pathology/paraneoplastic-syndromes-the-table-to-know/) - [The pulmonary circulation and hypoxic vasoconstriction](https://durgical.com/en/physiology/the-pulmonary-circulation-and-hypoxic-vasoconstriction/) - [Physiology of congenital shunts](https://durgical.com/en/physiology/physiology-of-congenital-shunts/) - [Bone tissue: cells, compact and spongy bone](https://durgical.com/en/histology/bone-tissue-cells-compact-and-spongy-bone/) ## What it is A syndrome of digital clubbing, new periosteal bone along the shafts of the tubular bones (periostosis) and joint pain or swelling. Clubbing is its most visible and common sign and may occur alone. Most cases are secondary to intrathoracic disease, especially lung cancer, so new clubbing in an adult is a reason to look for a serious underlying disease. A rare primary inherited form exists (pachydermoperiostosis). ## Who gets it Secondary forms account for about 95% of cases. Clubbing is common in lung cancer, cystic fibrosis, bronchiectasis and cyanotic congenital heart disease, and full hypertrophic osteoarthropathy occurs in a few percent of patients with non-small-cell lung cancer. In Colombia chronic suppurative lung disease after tuberculosis, interstitial lung disease and lung cancer in smokers are the main adult causes. The primary form begins around puberty and affects males far more often than females. ## Causes - Lung disease: lung cancer (especially non-small-cell), pleural tumours, bronchiectasis, cystic fibrosis, lung abscess, interstitial lung disease - Heart disease: cyanotic congenital heart disease, infective endocarditis - Gastrointestinal and liver disease: inflammatory bowel disease, celiac disease, cirrhosis - Other: Graves disease (thyroid acropachy), lymphoma - Primary form: mutations in HPGD or SLCO2A1 that raise prostaglandin E2 ## Risk factors - Smoking and lung cancer - Chronic lung infection or suppuration - Cyanotic heart disease with a right-to-left shunt - Chronic liver or bowel inflammatory disease - Family history (primary form) ## Pathophysiology The leading theory is that large platelet precursors (megakaryocyte fragments), normally trapped in the lung capillaries, bypass the lung through shunts or abnormal tumour vessels and lodge in the fingertip and periosteal capillaries. There they release growth factors (PDGF and VEGF) that cause vascular proliferation, oedema and fibroblast activity, producing clubbing and new bone formation. Raised prostaglandin E2, either inherited or tumour-related, also contributes. ## Classification - Isolated clubbing versus full hypertrophic osteoarthropathy (clubbing, periostosis and arthropathy) - Primary (pachydermoperiostosis, inherited) versus secondary - Generalised versus localised (for example one limb with an arterial aneurysm, or toes only with patent ductus arteriosus and reversed shunt) ## Symptoms and signs - Bulbous, rounded fingertips and toes with curved nails - Spongy, floating feel of the nail base - Deep, burning bone pain in the forearms and lower legs, worse when the legs hang down and eased by raising them - Symmetric joint pain and swelling of ankles, knees and wrists - Warm, thickened [skin](https://durgical.com/en/anatomy/skin/) over the ends of the limbs - In the primary form: thick, furrowed facial skin, oily skin and sweating of the hands and feet ## Red flags - New clubbing in an adult smoker, which needs chest imaging for lung cancer - Clubbing with weight loss, cough or haemoptysis - Clubbing with fever and a new heart murmur (infective endocarditis) - Clubbing in a patient with COPD or asthma, which these do not cause by themselves ## Diagnosis **Clinical** Clubbing is confirmed by loss of the normal angle between the nail and nail fold (Lovibond angle greater than 180 degrees), a positive Schamroth sign (no diamond-shaped window when the two index nails are placed back to back) and a fingertip depth greater than the depth at the last joint. The search then turns to the cause, guided by history and examination of the [chest](https://durgical.com/en/anatomy/region/chest/), heart, [abdomen](https://durgical.com/en/anatomy/region/abdomen/) and thyroid. **Tests** Chest X-ray and, often, chest CT in every adult with new clubbing. Pulse oximetry or arterial blood gas, echocardiography, [liver](https://durgical.com/en/anatomy/liver/) tests, celiac serology and thyroid tests as indicated. ESR may be raised; synovial fluid is non-inflammatory; rheumatoid factor is negative. **Imaging** Radiographs show smooth, symmetric periosteal new bone along the shafts of the [tibia](https://durgical.com/en/anatomy/tibia/), [fibula](https://durgical.com/en/anatomy/fibula/), [radius](https://durgical.com/en/anatomy/radius/) and [ulna](https://durgical.com/en/anatomy/ulna/), extending toward the ends of the bones as disease advances. Bone scintigraphy shows linear uptake along both cortical margins (tram-track sign) and is very sensitive. ## Differential diagnosis - Rheumatoid arthritis and other inflammatory arthritis - Thyroid acropachy in Graves disease - Venous stasis periostitis of the legs - Hypervitaminosis A and fluorosis - Pseudoclubbing from bone resorption (hyperparathyroidism, systemic sclerosis) - Familial or idiopathic clubbing without disease ## Goal of treatment Find and treat the underlying disease, which often makes pain disappear quickly and clubbing slowly regress, and relieve bone and joint pain when the cause cannot be removed. ## Treatment **Surgical** Surgical removal of an underlying lung tumour can relieve bone pain within days and lead to regression of the osteoarthropathy. **Medical** Treat other causes: control lung infection, correct cyanotic heart defects, treat endocarditis, liver or bowel disease; lung or liver transplant can reverse clubbing. **Medical** Symptom relief when the cause persists or in the primary form: NSAIDs, bisphosphonates, and occasionally glucocorticoids. **Follow-up** Monitoring: in adults with new clubbing, follow until a cause is found and repeat imaging if the first study is normal; recurrence of bone pain after cancer treatment may signal tumour recurrence. ## Complications - Chronic bone and joint pain that limits walking - Delayed diagnosis of the underlying lung cancer or infection - Joint effusions - Disfigurement of the face and limbs in the primary form ## Prognosis Prognosis is that of the underlying disease. Removing or controlling the cause usually relieves pain quickly and clubbing may regress over months. The primary form progresses for about a decade and then stabilises, with a normal life expectancy. ## Test yourself Think of the answer, then tap the question to see it. ## What is the most common cause of hypertrophic osteoarthropathy in adults? Lung cancer, especially non-small-cell lung cancer. ## What is the triad of hypertrophic osteoarthropathy? Digital clubbing, periostosis of the tubular bones and arthritis or arthralgia. ## Does uncomplicated COPD cause clubbing? No; clubbing in a patient with COPD should prompt a search for lung cancer, bronchiectasis or another cause. ## What does the Schamroth sign test? Clubbing: the normal diamond-shaped window between two opposed index fingernails is lost. ## What is the characteristic bone scan finding? Symmetric linear uptake along the cortices of long bones (tram-track or double-stripe sign). [Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/hypertrophic-osteoarthropathy-and-digital-clubbing/) ## Related conditions - [Lung cancer](https://durgical.com/en/conditions/lung-cancer/) - [Bronchiectasis](https://durgical.com/en/conditions/bronchiectasis/) - [Cystic fibrosis](https://durgical.com/en/conditions/cystic-fibrosis/) - [Lung abscess](https://durgical.com/en/conditions/lung-abscess/) - [Interstitial lung disease](https://durgical.com/en/conditions/interstitial-lung-disease/) - [Malignant pleural mesothelioma](https://durgical.com/en/conditions/malignant-pleural-mesothelioma/) - [Tetralogy of Fallot](https://durgical.com/en/conditions/tetralogy-of-fallot/) - [Truncus arteriosus, TAPVR and tricuspid atresia](https://durgical.com/en/conditions/truncus-arteriosus-tapvr-and-tricuspid-atresia/) - [Infective endocarditis](https://durgical.com/en/conditions/infective-endocarditis/) - [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/) - [Crohn disease](https://durgical.com/en/conditions/crohn-disease/) - [Ulcerative colitis](https://durgical.com/en/conditions/ulcerative-colitis/) - [Coeliac disease](https://durgical.com/en/conditions/coeliac-disease/) - [Graves disease (hyperthyroidism)](https://durgical.com/en/conditions/graves-disease/) - [Hodgkin lymphoma](https://durgical.com/en/conditions/hodgkin-lymphoma/) - [Rheumatoid arthritis](https://durgical.com/en/conditions/rheumatoid-arthritis/) Educational information, not medical advice. For any symptom, see a health professional. Sources: [Hypertrophic osteoarthropathy](https://radiopaedia.org/articles/hypertrophic-osteoarthropathy) (Radiopaedia, 2026); [Clubbing of the fingers or toes: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/003282.htm) (MedlinePlus (U.S. National Library of Medicine), 2026); [Pachydermoperiostosis - Symptoms, Causes, Treatment | NORD](https://rarediseases.org/rare-diseases/pachydermoperiostosis/) (National Organization for Rare Disorders (NORD), 2026). [← All conditions](https://durgical.com/en/conditions/) ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/conditions/hypertrophic-osteoarthropathy-and-digital-clubbing/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/hypertrophic-osteoarthropathy-and-digital-clubbing/