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