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Clubbing

Synonyms: hippocratic nails, hippocratic fingers (first described by Hippocrates)

This describes an increase in the soft tissue around the end of the fingers and toes.The swelling is painless and usually bilateral, unless a localised vascular abnormality exists. There is no change to the underlying bone. The nail base eventually becomes convex and extends halfway up the nail.
Clubbing is thought to result from changes to the volume of interstitial fluid and increased blood flow to the area, but the exact pathophysiology remains unknown.1
Primary clubbing may be idopathic or be a feature of an inherited condition. Secondary clubbing may be caused by a wide range of diseases.

Causes

Causes of Clubbing1

Primary
  • Pachydermoperiostosis - characterised by periostosis, 89% of patients also have clubbing2
  • Familial clubbing3
  • Hypertrophic osteoarthropathy (a syndrome which also includes chronic proliferative periostitis of the long bones and joint swelling)
Pulmonary disease
Cardiac disease
Gastrointestinal disease Skin disease
  • Bureau-Barri?re-Thomas syndrome (digital clubbing associated with palmoplantar keratoderma)
  • Fischer syndrome (keratosis palmaris et plantaris, hair hypoplasia, onycholysis and onychogryphosis)
  • Palmoplantar keratoderma (diffuse patches on the palms and soles)
Malignancies
Miscellaneous conditions

Epidemiology

Pachydermoperiostosis is a rare disease. 96 cases were reported in the literature between 1947 and 1990, and approximately 50 cases between 1990 and 2004.2

The epidemiology of secondary clubbing depends on the cause.

Presentation

The patient may notice a swelling of the distal portion of the fingers or toes, but the onset is usually so gradual as to make this a rare occurrence. Even more rarely, the patient may notice some discomfort, because most clubbing is painless. The majority of clubbing is detected by doctors as part of a routine examination for other presenting symptoms.

Clubbing has been described as a bulbous fusiform enlargement of the distal portion of a digit. It is commonly bilateral but may be unilateral, and can affect a single digit. Both fingers and toes can be affected.

As clubbing progresses, the angle between the nail and the nail base (called the Lovibond angle) becomes obliterated. Normally, the angle is less than or equal to 160°. With increasing convexity of the nail, the angle becomes greater than 180°. In early clubbing, the nail may feel springy instead of firm when palpated, and the skin at the base of the nail may become smooth and shiny.

In individuals without clubbing, if two opposing fingers are placed together, a diamond-shaped window will appear. In clubbing, this window is obliterated, and the distal angle formed by the two nails becomes wider. This is known as Schamroth's window test.

CLUBBING (OM351a.jpg)

Differential Diagnosis

Pseudoclubbing - this is overcurvature of the nails in both the longitudinal and transverse axes, with preservation of a normal Lovibond angle.4 Pseudoclubbing may be seen in renal failure,5 hyperparathyroidism,4 and sarcoidosis.6

Investigations

Laboratory investigations

These will depend on the underlying conditions suggested by the overall clinical picture.

Imaging

This is not usually required to diagnose clubbing, but plain radiographs of the digits may help to elucidate the cause. Osteolysis is often seen in patients with congenital cyanotic heart disease, whilst bone hypertrophy suggests a pulmonary condition.1 CT and MRI scanning of other areas may be required to assist in diagnosing the underlying primary cause.

Management

This will be dictated by the underlying disease process.

Prognosis1

Clubbing is potentially reversible if the underlying condition is treated early enough, but the changes may be irreversible once collagen deposition has set in.


Document References
  1. Schwartz R, Richards G; Clubbing of the Nail eMedicine.com 2006
  2. Auger M, Stavrianeas N; Pachydermoperiostosis Orpha.net 2004
  3. Horsfall F; Congenital Familial Clubbing of the Fingers and Toes Can Med Assoc J. 1936 February; 34(2): 145?149
  4. Farzaneh-Far A; Images in clinical medicine. Pseudoclubbing. N Engl J Med. 2006 Apr 13;354(15):e14.
  5. Rault R, Carpenter B; Pseudoclubbing in chronic renal failure. Q J Med. 1989 Nov;73(271):1063-9. [abstract]
  6. Lieberman J, Krauthammer M; Pseudoclubbing in a patient with sarcoidosis of the phalangeal bones. Arch Intern Med. 1983 May;143(5):1017-9. [abstract]
Acknowledgements EMIS is grateful to Dr Laurence Knott for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 1971
Document Version: 20
DocRef: bgp72
Last Updated: 21 Mar 2007
Review Date: 20 Mar 2009










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