This 52 year old man presented with painless, puffy, swelling of his hands and fingers. He was clinically and biochemically euthyroid, but six years before he had been treated for thyrotoxicosis. Hand radiographs showed asymmetric metacarpal periostitis.  Although thyroid acropachy is usually considered a complication of Graves disease,1 it characteristically develops several years after the onset of hyperthyroidism, particularly following treatment. Clinical findings include painless swelling of fingers and toes, clubbing, exopthalmos, and pre-tibial myxoedema. The characteristic radiographic finding is asymmetric ‘feathery’ periostitis of the metacarpal and metatarsal bones. Histologically there is soft tissue infiltration with myxoedematous tissue, periosteal nodular fibrosis, and new bone formation. There is no specific treatment.‘Feathery’ periostitis limited to the hands and feet is not typical of hypertrophic pulmonary osteoarthropathy, the principal differential diagnosis.

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