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FINGER CLUBBING
By Dr. Samuel2 Alawode
(M.D DTMU, Georgia)
(HO, Cardiology Unit, UCH, Ibadan)
1
OUTLINE
• INTRODUCTION
• CAUSES
• EPIDEMIOLOGY
• PATHOPHYSIOLOGY
• GRADING
• CLINICAL ASSESSMENT
• DIAGNOSTIC AIDS
• MANAGEMENT/TREATMENT
• CONCLUSION
• REFERENCES 2
INTRODUCTION
• Clubbing was first described by Hippocrates
nearly 2500 years ago in a patient with
Chronic Empyema.
He wrote: "The nails of the hand are bent; the fingers
are hot especially in their extremities."
• It is often described as Hippocratic finger and
regarded to be the oldest sign in clinical
medicine 3
INTRODUCTION
• Clubbing is the bulbous fusiform enlargement of the soft
tissue of the terminal phalanx of a digit
• It is characterized in its early stage by filling in of the
normally obtuse angle between the proximal end of the
nail and the adjoining soft tissues (lovibond’s angle) and
increased curvature of the nails in both planes (transverse
and longitudinal) 4
INTRODUCTION
• The Lovibond’s angle – The
angle between the proximal
nail fold and the nail bed
• This angle is typically less
than or equal to 160°
5
INTRODUCTION
• In clubbing, the angle flattens out and
increases as the severity of the clubbing
increases
• If the angle is greater than 180°, definitive
clubbing exists.
• An angle between 160-180° falls in a gray
area and may indicate early stages of
clubbing or a pseudoclubbing
phenomenon. 6
7
CAUSES
• Hereditary
Frequently transmits as a dominant trait (e.g
Pachydermoperiostosis – Finger Clubbing, pachydermia
(thickening of the facial skin and/or scalp), and
periostosis (swelling of periarticular tissue and
subperiosteal new bone formation)
• Idiopathic
• Acquired (Most common) 8
CAUSES
(ACQUIRED)
• Lung (primary and metastatic lung
cancer, asbestosis, sarcoidosis, lung
abscess, cystic fibrosis, tuberculosis,
and mesothelioma)
• Occupational – Jackhammer Operators
Chronic emphysema and bronchitis don’t cause
clubbing. The presence of clubbing in a patient
with COPD should prompt a search for an
underlying (lung) cancer, bronchiectasis or
interstitial lung disease 9
CAUSES (UNILATERAL CLUBBING)
Asymmetrical clubbing usually indicates impaired regional blood
flow caused by localized vascular disease or hemiplegia.
• Hemiplegia
• Aneurysm of subclavian artery, brachio-cephalic trunk, aortic
arch, axillary artery, palmer arch
• Presubclavian coarctation of aorta (left sided clubbing)
• AV fistula used for hemodialysis
• Infected arterial graft 10
CAUSES (DIFFERENTIAL CLUBBING)
• This is clubbing involving the lower limb
digits only
• Caused by reversal of shunting in PDA
• Eisenmenger syndrome: deoxygenated
blood from the right ventricle flows
through the shunt into the Aorta, distal
to the Left subclavian artery therefore
sparing the upper limbs, causing
Cyanosis and clubbing of the lower limb
digits 11
EPIDEMIOLOGY
• The incidence can be difficult to estimate given the numerous underlying
etiologies
• In general, clubbing is seen in roughly 1% of all internal medicine
admissions and is associated with serious underlying disease in 40% of
those patients
• In adults, the most common pulmonary cause of clubbing is
lung malignancy
• Despite being such a predominant cause of clubbing, clubbing is
prevalent in only 5% to 15% of lung cancer patients 12
EPIDEMIOLOGY
• In Nigerians, The cause of finger clubbing is predominantly pulmonary in
origin, being responsible in 84 per cent of cases. The commonest cause is
bronchiectasis, followed by empyema thoracis, bronchial carcinoma and
lung abscess. Among the nonpulmonary causes are infective
endocarditis, endomyocardial fibrosis and cirrhosis of liver [7]
• Finger clubbing was observed in 21% of 70 adult Nigerian patients
presenting with pulmonary tuberculosis. These patients had a significantly
higher incidence of haemoptysis and they also showed a significantly
lower body weight and serum albumin than those without clubbing. [8]
13
EPIDEMIOLOGY
• In Children and adolescents, diseases with high pooled prevalence of
clubbing include HIV Infection (29.1%), Hemoglobinopathies (23%), Cystic
Fibrosis (19.5%) and Tuberculosis (17.1%) [6]
14
PATHOPHYSIOLOGY
• Although many explanatory theories have been put
forward, the etiology of clubbing is unknown
• The main pathologic finding in clubbing is increased
capillary density in the distal phalanx
• 2 Major theories :
A neurocirculatory reflex and Platelet hypothesis
15
PATHOPHYSIOLOGY (NEUROCIRCULATORY
REFLEX)
• According to the Neurocirculatory reflex theory, there is a reflex in
which afferent impulses travel by the vagus nerve from the inciting
focus (such as a lung tumor) to the central nervous system.
• The efferent limb of the proposed reflex is unknown
• Presumably some humoral substance or neural impulse mediates the
vascular changes leading to increased blood flow through multiple
arteriovenous shunts in the distal phalanges. Increased blood flow
then leads to tissue hypertrophy and hyperplasia on a nutritional
basis.
16
PATHOPHYSIOLOGY (PLATELET HYPOTHESIS)
• Megakaryocytes would normally break up in the pulmonary capillaries
to the platelets but in the presence shunts or abnormal circulation
within a neoplasm, these megakaryocytes bypass the pulmonary
capillaries and reach the systemic circulation to preferentially lodge in
the tips of the digits
• These cells locally release Platelet Derived Growth Factor (PDGF) and
VEGF along with other mediators that increase vascularity, endothelial
permeability and activate connective tissue cells including fibroblasts
• The release of both PDGF and VEGF is thought to be enhanced by
hypoxia 17
18
GRADING
• 1: Fluctuation and softening of nail-beds
• 2: Obliteration of the Lovibond angle (>160º)
• 3: Accentuated convexity of nail (Parrot beak)
• 4: Clubbed appearance of the fingertip
(Drum stick appearance)
• 5: Development of a shiny or glossy change in nail and adjacent skin with
longitudinal striations
(Hypertrophic Osteoarthropathy)
19
20
CLINICAL ASSESSMENT OF FINGER CLUBBING
Lovibond’s profile sign: Bring the
patient’s fingertip at the level of
your eye and look tangentially for
the lovibond’s angle.
Normal: less than or equal to 160º
Clubbing: more than or equal to
180º
21
CLINICAL ASSESSMENT OF FINGER CLUBBING
Curth’s modified profile
sign: Similarly, you can measure the
angle between the middle and distal
phalanx.
Normal: 180º
Clubbing: less than 160º
22
CLINICAL ASSESSMENT OF FINGER CLUBBING
Fluctuation test: The patients fingertip is
placed on the pulp of examiner’s two thumbs
and held in this position by gentle pressure
with the tips of examiner’s middle fingers
applied on the patient’s proximal
interphalangeal joint. The patient’s finger is
then palpated over the base of the nail by the
tips of examiner’s index fingers. There is
increased fluctuation of the nail bed in
clubbing due to softening of the nail-bed 23
CLINICAL ASSESSMENT OF FINGER CLUBBING
Schamroth’s window test: The sign is
elicited by placing the dorsal surfaces
of terminal phalanges on opposing
fingers together. The normally formed
diamond shaped window is obliterated
in the presence of clubbing. This sign is
also known as diamond sign.
24
• Drumstick type clubbing: Bronchiectasis, Congenital cyanotic heart
disease (Mnemonic: BCD)
• Parrot-beak type clubbing: Bronchiogenic carcinoma
• Painful clubbing: Bronchiogenic carcinoma, SABE, Lung abscess
• Uni-digital clubbing: Hereditary, Repeated local trauma, Median nerve
injury, Sarcoidosis
• Clubbing with cyanosis: Cyanotic heart disease, Pulmonary AV shunt,
Pulmonary disease like lung abscess, bronchiectasis, cystic fibrosis
• Acute clubbing (Clubbing within 2 weeks after onset of illness): Lung
abscess, Empyema thoracis
DIAGNOSTIC AIDS
25
MANAGEMENT/TREATMENT
• No specific treatment for clubbing is available. The underlying condition should be
treated
• Treatment of the underlying pathological condition may decrease the clubbing or,
potentially, reverse it if performed early enough
Leo Schamroth, the cardiologist after whom Schamroth's sign was named, noticed
the loss of the window as one of the earliest signs of clubbing when he was
diagnosed with subacute bacterial endocarditis. He also reported that the window
reappeared two months after his endocarditis had been successfully treated.
26
CONCLUSION
• Clubbing is the bulbous enlargement of the soft tissue of the distal phalanx with
Increase in the Lovibond’s angle and increased curvature of the longitudinal and
transverse plane of the nail
• It is often caused by an underlying disease
• In adults, consider Lung, GI and Heart diseases
• In children, it's important to consider not only lung, liver, and heart diseases but
also conditions such as HIV infection, hemoglobinopathies, and tuberculosis.
• It often regresses after treatment of the underlying cause 27
REFERENCES
1. Burcovschii S, Aboeed A. Nail Clubbing. [Updated 2022 Sep 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539713/
2. McPhee SJ. Clubbing. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory
Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 44. Available from: https://www.ncbi.nlm.nih.gov/books/NBK366/
3. Epomedicine. Digital clubbing. 2023 Oct 8. https://epomedicine.com/clinical-medicine/physical-examination-digital-clubbing/
4. Robert A. Schwartz, Supriya goyal. Pachydermoperiostosis. Medscape. 2021 April 06.
https://emedicine.medscape.com/article/1075122-overview#a4
5. Robert A. Schwartz, Gregory M. Richards. Clubbing of the nails. Medscape. 2023 March 15.
https://emedicine.medscape.com/article/1105946-overview#a1
6. Mickael Essouma et al. Epidemiology of Digital Clubbing and Hypertrophic Osteoarthropathy: A Systematic Review and
Meta-analysis. March 2022, 28(2):104-110 . DOI: 10.1097/RHU.0000000000001830
7. Onadeko BO, Kolawole TM. The clinical and aetiological pattern of finger clubbing and hypertrophic osteoarthropathy in
Nigerians. Trop Geogr Med. 1979 Jun;31(2):191-9. PMID: 505549.
8. Macfarlane JT, Ibrahim M, Tor-Agbidye S. The importance of finger clubbing in pulmonary tuberculosis. Tubercle. 1979 Mar;60(1):45-8. doi: 10.1016/0041-
3879(79)90055-2. PMID: 452121.
28
29

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Finger Clubbing by Dr. Samuel2 Alawode.pptx

  • 1. FINGER CLUBBING By Dr. Samuel2 Alawode (M.D DTMU, Georgia) (HO, Cardiology Unit, UCH, Ibadan) 1
  • 2. OUTLINE • INTRODUCTION • CAUSES • EPIDEMIOLOGY • PATHOPHYSIOLOGY • GRADING • CLINICAL ASSESSMENT • DIAGNOSTIC AIDS • MANAGEMENT/TREATMENT • CONCLUSION • REFERENCES 2
  • 3. INTRODUCTION • Clubbing was first described by Hippocrates nearly 2500 years ago in a patient with Chronic Empyema. He wrote: "The nails of the hand are bent; the fingers are hot especially in their extremities." • It is often described as Hippocratic finger and regarded to be the oldest sign in clinical medicine 3
  • 4. INTRODUCTION • Clubbing is the bulbous fusiform enlargement of the soft tissue of the terminal phalanx of a digit • It is characterized in its early stage by filling in of the normally obtuse angle between the proximal end of the nail and the adjoining soft tissues (lovibond’s angle) and increased curvature of the nails in both planes (transverse and longitudinal) 4
  • 5. INTRODUCTION • The Lovibond’s angle – The angle between the proximal nail fold and the nail bed • This angle is typically less than or equal to 160° 5
  • 6. INTRODUCTION • In clubbing, the angle flattens out and increases as the severity of the clubbing increases • If the angle is greater than 180°, definitive clubbing exists. • An angle between 160-180° falls in a gray area and may indicate early stages of clubbing or a pseudoclubbing phenomenon. 6
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  • 8. CAUSES • Hereditary Frequently transmits as a dominant trait (e.g Pachydermoperiostosis – Finger Clubbing, pachydermia (thickening of the facial skin and/or scalp), and periostosis (swelling of periarticular tissue and subperiosteal new bone formation) • Idiopathic • Acquired (Most common) 8
  • 9. CAUSES (ACQUIRED) • Lung (primary and metastatic lung cancer, asbestosis, sarcoidosis, lung abscess, cystic fibrosis, tuberculosis, and mesothelioma) • Occupational – Jackhammer Operators Chronic emphysema and bronchitis don’t cause clubbing. The presence of clubbing in a patient with COPD should prompt a search for an underlying (lung) cancer, bronchiectasis or interstitial lung disease 9
  • 10. CAUSES (UNILATERAL CLUBBING) Asymmetrical clubbing usually indicates impaired regional blood flow caused by localized vascular disease or hemiplegia. • Hemiplegia • Aneurysm of subclavian artery, brachio-cephalic trunk, aortic arch, axillary artery, palmer arch • Presubclavian coarctation of aorta (left sided clubbing) • AV fistula used for hemodialysis • Infected arterial graft 10
  • 11. CAUSES (DIFFERENTIAL CLUBBING) • This is clubbing involving the lower limb digits only • Caused by reversal of shunting in PDA • Eisenmenger syndrome: deoxygenated blood from the right ventricle flows through the shunt into the Aorta, distal to the Left subclavian artery therefore sparing the upper limbs, causing Cyanosis and clubbing of the lower limb digits 11
  • 12. EPIDEMIOLOGY • The incidence can be difficult to estimate given the numerous underlying etiologies • In general, clubbing is seen in roughly 1% of all internal medicine admissions and is associated with serious underlying disease in 40% of those patients • In adults, the most common pulmonary cause of clubbing is lung malignancy • Despite being such a predominant cause of clubbing, clubbing is prevalent in only 5% to 15% of lung cancer patients 12
  • 13. EPIDEMIOLOGY • In Nigerians, The cause of finger clubbing is predominantly pulmonary in origin, being responsible in 84 per cent of cases. The commonest cause is bronchiectasis, followed by empyema thoracis, bronchial carcinoma and lung abscess. Among the nonpulmonary causes are infective endocarditis, endomyocardial fibrosis and cirrhosis of liver [7] • Finger clubbing was observed in 21% of 70 adult Nigerian patients presenting with pulmonary tuberculosis. These patients had a significantly higher incidence of haemoptysis and they also showed a significantly lower body weight and serum albumin than those without clubbing. [8] 13
  • 14. EPIDEMIOLOGY • In Children and adolescents, diseases with high pooled prevalence of clubbing include HIV Infection (29.1%), Hemoglobinopathies (23%), Cystic Fibrosis (19.5%) and Tuberculosis (17.1%) [6] 14
  • 15. PATHOPHYSIOLOGY • Although many explanatory theories have been put forward, the etiology of clubbing is unknown • The main pathologic finding in clubbing is increased capillary density in the distal phalanx • 2 Major theories : A neurocirculatory reflex and Platelet hypothesis 15
  • 16. PATHOPHYSIOLOGY (NEUROCIRCULATORY REFLEX) • According to the Neurocirculatory reflex theory, there is a reflex in which afferent impulses travel by the vagus nerve from the inciting focus (such as a lung tumor) to the central nervous system. • The efferent limb of the proposed reflex is unknown • Presumably some humoral substance or neural impulse mediates the vascular changes leading to increased blood flow through multiple arteriovenous shunts in the distal phalanges. Increased blood flow then leads to tissue hypertrophy and hyperplasia on a nutritional basis. 16
  • 17. PATHOPHYSIOLOGY (PLATELET HYPOTHESIS) • Megakaryocytes would normally break up in the pulmonary capillaries to the platelets but in the presence shunts or abnormal circulation within a neoplasm, these megakaryocytes bypass the pulmonary capillaries and reach the systemic circulation to preferentially lodge in the tips of the digits • These cells locally release Platelet Derived Growth Factor (PDGF) and VEGF along with other mediators that increase vascularity, endothelial permeability and activate connective tissue cells including fibroblasts • The release of both PDGF and VEGF is thought to be enhanced by hypoxia 17
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  • 19. GRADING • 1: Fluctuation and softening of nail-beds • 2: Obliteration of the Lovibond angle (>160º) • 3: Accentuated convexity of nail (Parrot beak) • 4: Clubbed appearance of the fingertip (Drum stick appearance) • 5: Development of a shiny or glossy change in nail and adjacent skin with longitudinal striations (Hypertrophic Osteoarthropathy) 19
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  • 21. CLINICAL ASSESSMENT OF FINGER CLUBBING Lovibond’s profile sign: Bring the patient’s fingertip at the level of your eye and look tangentially for the lovibond’s angle. Normal: less than or equal to 160º Clubbing: more than or equal to 180º 21
  • 22. CLINICAL ASSESSMENT OF FINGER CLUBBING Curth’s modified profile sign: Similarly, you can measure the angle between the middle and distal phalanx. Normal: 180º Clubbing: less than 160º 22
  • 23. CLINICAL ASSESSMENT OF FINGER CLUBBING Fluctuation test: The patients fingertip is placed on the pulp of examiner’s two thumbs and held in this position by gentle pressure with the tips of examiner’s middle fingers applied on the patient’s proximal interphalangeal joint. The patient’s finger is then palpated over the base of the nail by the tips of examiner’s index fingers. There is increased fluctuation of the nail bed in clubbing due to softening of the nail-bed 23
  • 24. CLINICAL ASSESSMENT OF FINGER CLUBBING Schamroth’s window test: The sign is elicited by placing the dorsal surfaces of terminal phalanges on opposing fingers together. The normally formed diamond shaped window is obliterated in the presence of clubbing. This sign is also known as diamond sign. 24
  • 25. • Drumstick type clubbing: Bronchiectasis, Congenital cyanotic heart disease (Mnemonic: BCD) • Parrot-beak type clubbing: Bronchiogenic carcinoma • Painful clubbing: Bronchiogenic carcinoma, SABE, Lung abscess • Uni-digital clubbing: Hereditary, Repeated local trauma, Median nerve injury, Sarcoidosis • Clubbing with cyanosis: Cyanotic heart disease, Pulmonary AV shunt, Pulmonary disease like lung abscess, bronchiectasis, cystic fibrosis • Acute clubbing (Clubbing within 2 weeks after onset of illness): Lung abscess, Empyema thoracis DIAGNOSTIC AIDS 25
  • 26. MANAGEMENT/TREATMENT • No specific treatment for clubbing is available. The underlying condition should be treated • Treatment of the underlying pathological condition may decrease the clubbing or, potentially, reverse it if performed early enough Leo Schamroth, the cardiologist after whom Schamroth's sign was named, noticed the loss of the window as one of the earliest signs of clubbing when he was diagnosed with subacute bacterial endocarditis. He also reported that the window reappeared two months after his endocarditis had been successfully treated. 26
  • 27. CONCLUSION • Clubbing is the bulbous enlargement of the soft tissue of the distal phalanx with Increase in the Lovibond’s angle and increased curvature of the longitudinal and transverse plane of the nail • It is often caused by an underlying disease • In adults, consider Lung, GI and Heart diseases • In children, it's important to consider not only lung, liver, and heart diseases but also conditions such as HIV infection, hemoglobinopathies, and tuberculosis. • It often regresses after treatment of the underlying cause 27
  • 28. REFERENCES 1. Burcovschii S, Aboeed A. Nail Clubbing. [Updated 2022 Sep 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539713/ 2. McPhee SJ. Clubbing. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 44. Available from: https://www.ncbi.nlm.nih.gov/books/NBK366/ 3. Epomedicine. Digital clubbing. 2023 Oct 8. https://epomedicine.com/clinical-medicine/physical-examination-digital-clubbing/ 4. Robert A. Schwartz, Supriya goyal. Pachydermoperiostosis. Medscape. 2021 April 06. https://emedicine.medscape.com/article/1075122-overview#a4 5. Robert A. Schwartz, Gregory M. Richards. Clubbing of the nails. Medscape. 2023 March 15. https://emedicine.medscape.com/article/1105946-overview#a1 6. Mickael Essouma et al. Epidemiology of Digital Clubbing and Hypertrophic Osteoarthropathy: A Systematic Review and Meta-analysis. March 2022, 28(2):104-110 . DOI: 10.1097/RHU.0000000000001830 7. Onadeko BO, Kolawole TM. The clinical and aetiological pattern of finger clubbing and hypertrophic osteoarthropathy in Nigerians. Trop Geogr Med. 1979 Jun;31(2):191-9. PMID: 505549. 8. Macfarlane JT, Ibrahim M, Tor-Agbidye S. The importance of finger clubbing in pulmonary tuberculosis. Tubercle. 1979 Mar;60(1):45-8. doi: 10.1016/0041- 3879(79)90055-2. PMID: 452121. 28
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