Clubbing, also known as Hippocratic fingers, is a thickening of tissues at the base of fingernails and toenails such that the normal angle between the nail and digit is filled in. It is caused by increased levels of vascular endothelial growth factor (VEGF) which induces vascular changes and tissue proliferation in the nails. Common causes include lung diseases like bronchitis and lung cancer, as well as non-lung conditions such as liver cirrhosis and inflammatory bowel disease. Clubbing can range from nail bed fluctuation to severe bony changes in the fingers known as hypertrophic osteoarthropathy.

1. CLUBBING
First described by Hippocrates about
2500yrs ago, hence also called as
Hippocratic finger
ABHIJIT SAMAL
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2. DEFINITION
• Thickening of the tissues at the base of the
finger and toe nails such that the normal angle
between the nail & the digit is filled in.

3. Pathophysiology
• VEGF is the key entity, platelet derived growth
factor stimulated by hypoxia and produced in
diverse malignancies.
• VEGF induces vascular hyperplasia, edema,
and fibroblast or osteoblast proliferation at
peripheral levels in nails

4. CAUSES
• thoracic & non-thoracic
• THORACIC causes: bronchitis, empyema, lung abscess, cystic
fibrosis, Lung Ca, Esophageal Ca,
mesothelioma, Bac. Endocarditis.
» Interstitial lung disease: asbestosis, fibrosing
alveolitis.
» Vascular causes: AV malformations, Cyanotic
heart disease.
• Non-thoracic causes: Hepatic cirrhosis, Ulcerative colitis,
Crohn’s disease.

5. Criteria
• Loss of normal angle between nail and nail
bed.
• Inc. Nail bed fluctuation
• Inc. nail bed curvature in the later stages
• Inc. bulk of soft tissue over the terminal
phalanges

7. Grades of clubbing
• Grade 1: Nail bed fluctuation
• Grade 2: Obliteration of Lovibond angle
• Grade 3: Parrot beaking
• Grade 4: Hypertrophic osteo-
arthropathy(HOA)

8. Parrot beak app.
Drumstick appearance

9. Hypertrophic Osteo-arthropathy
• Earlier known as hypertrophic pulmonary
osteo-arthropathy(HPOA)
• Syndrome of clubbing of the digits, periostitis
of the long bones and arthritis.
• Primary: occurs w/o any underlying cause and
is familial
• Secondary: pulmonary, cardiac, hepatic,
intestinal disease.

10. Hypertrophic Osteo-arthropathy
• Earlier known as hypertrophic pulmonary
osteo-arthropathy(HPOA)
• Syndrome of clubbing of the digits, periostitis
of the long bones and arthritis.
• Primary: occurs w/o any underlying cause and
is familial
• Secondary: pulmonary, cardiac, hepatic,
intestinal disease.