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CLUBBING

Clubbing is an increase in the soft tissue under the proximal nail plate of the distal
part of the fingers or toes. Its causes are varied, the mechanism unknown (1).
Clubbing was first described by Hippocrates in 400 BC in an empyema patient (hence
also known as hippocratic fingers) (2).
Initially, increased vascularity of the nail bed results in increased sponginess of
the proximal nail plate which may be detected by compressing the nail bed and finger (1).
Later, swelling of the soft tissue causes a broadening of the distal phalanx and an increase
in the transverse and longitudinal curvature of the nail (3). The overlying skin stretches
and takes on a polished appearance.
Clubbing may be hereditary, idiopathic or acquired (3).

It may also present as


unilateral clubbing - associated with hemiplegia and vascular lesions
bilateral clubbing - associated with neoplastic, pulmonary, cardiac, gastrointestinal,
infectious, endocrine, vascular and multisystemic disease (3).
The nail is pushed up, increasing the angle between the long axis of the nail and
the dorsal nail fold (also known as Lovibond’s angle), which approaches 180 degrees in
severe cases (3).
Clubbing may be demonstrated clinically by apposing the dorsal surfaces of two
nails - the diamond shaped window seen in normal nails is abolished in the clubbed nail
(Schamroth sign) (1).
Patients hardly ever notice that they have clubbing, even when it is severe. They
often express surprise at their doctor's interest in such an unlikely part of their anatomy.
In case of clubbing involving a single digit, the diagnosis of pseudoclubbing
should be ruled out. Causes of single digit clubbing include - Idiopathic, digital mucoid
cyst, osteoid osteoma and myxochondroma (2).

Theories about the mechanism of clubbing


One theory is that clubbing is a response to arterial hypoxaemia, in which release
of an unknown humoral substance causes dilation of the vessels of the fingers and the
toes.
Another is that clubbing results from a neurovascular abnormality. In support of
this is the fact that a vagal section may reverse clubbing.
Recent research studies have shown that platelet-derived growth factors and
vascular endothelial growth factors (which are released when platelet precursors are
trapped in the peripheral circulation) acts as promoters of vascularity and eventually
finger clubbing (1).
However, no theory adequately explains the sheer variety of diseases in which this
phenomenon occurs.

Criteria for diagnosis


All four of the features outlined below should be present before the fingernails
can be said to be clubbed:
 Increased sponginess of the nail bed
 Loss of the usual acute angle between the nail and the nail bed
 Increased curvature of the nail
 Increased mass of the soft tissues over the terminal phalanges

Etiology by frequency
Here the causes of clubbing are grouped with respect to frequency.

Common causes of clubbing


Common causes of finger clubbing can be divided up according to the system with primary
pathology:
 Cardiovascular causes:
o Cyanotic congenital heart disease
o Infective endocarditis
 Respiratory causes:
o Lung carcinoma - usually squamous cell carcinoma
o pulmonary fibrosis, especially fibrosing alveolitis
o cystic fibrosis
o chronic pulmonary suppuration:
 Bronchiectasis
 Empyema
 Lung abscess

The clubbing seen with bronchogenic carcinoma is often part of a hypertrophic


osteoarthropathy.

Uncommon causes of clubbing

Uncommon causes of finger clubbing can be divided up according to the system


with primary pathology:

• Cardiovascular causes:
o Atrial myxoma

• Respiratory causes:
o Tuberculosis - typically within 6 weeks of onset
o Pleural mesothelioma

• Gastrointestinal causes:
o Liver cirrhosis
o Ulcerative colitis
o Crohn's disease
o Coeliac disease

• Endocrinological:
o Thyroid acropachy in thyrotoxicosis
Rare causes of clubbing
Rare causes of clubbing include:
 Familial - usually before the age of puberty
 Neurodiaphragmatic tumour

Etiology by site
Sites of causes of clubbing include:
 Cardiac
 Respiratory
 Gastrointesinal
 Endocrine

1. Cardiac
Cardiac causes include:
 Cyanotic congenital heart disease
 Infective endocarditis
 Atrial myxoma

2. Respiratory
Respiratory causes include:
 Lung carcinoma - not usually small cell carcinoma
 Pulmonary fibrosis, especially fibrosing alveolitis
 Cystic fibrosis
 Chronic pulmonary suppuration, e.g.:
o Bronchiectasis
o Empyema
o Lung abscess
• Tuberculosis - typically within 6 weeks of onset
• Pleural mesothelioma

3. Gastrointestinal
Gastrointestinal causes include
 Liver cirrhosis
 Ulcerative colitis
 Crohn's disease
 Coeliac disease
 Small bowel lymphoma

4. Endocrine
Endocrinological causes include:
Thyrotoxicosis: in this condition clubbing is termed thyroid acropachy although this
looks like clubbing and is clubbing

Unilateral clubbing
Unilateral clubbing may be caused by:
 Bronchial arteriovenous aneurysm
 Axillary artery aneurysm
 Idiopathic