Digital clubbing is one of the oldest recognised signs in medicine, first formally documented by Hippocrates nearly 2500 years ago. For this reason, it is also known as “Hippocratic fingers”.

It is an important clinical sign that can assist in the diagnosis of a variety of conditions, particularly when found in conjunction with other symptoms and signs. Digital clubbing is characterised by a painless and bilateral increase in the soft tissue around the end of the fingers and toes.

 

Pathogenesis

The exact pathogenesis of digital clubbing is not fully understood, but it is thought to result from changes to the volume of interstitial fluid and increased blood flow to the area. Platelet-derived growth factor and vascular endothelial growth factor are believed to be involved in this process.

 

Aetiology

Digital clubbing is associated with a wide variety of clinical condition. The commonest causes lung diseases, with neoplastic lung disease being the most common respiratory cause of clubbing.

The following table summarises the most common causes:

 

System involvedExamples
Primary clubbingPrimary hypertrophic osteoarthropathy (pachydermoperiostosis)
Genetic (familial clubbing)
Hypertrophic osteoarthropathy
Cardiac diseaseCyanotic congenital heart disease
Bacterial endocarditis
Respiratory diseaseLung cancer
Tuberculosis
Bronchiectasis
Cystic fibrosis
Interstitial lung disease
Cryptogenic fibrosing alveolitis
Idiopathic pulmonary fibrosis
Sarcoidosis
Empyema
Pleural mesothelioma
Pulmonary metastases
Gastrointestinal diseaseUlcerative colitis
Crohn's disease
Primary biliary cirrhosis
Cirrhosis of the liver
Oesophageal achalasia
Peptic ulceration
Endocrine diseaseAcromegaly
Thyroid acropachy
Dermatological disease Bureau-Barrière-Thomas syndrome
Fischer's syndrome
Palmoplantar keratoderma
MalignancyThyroid cancer
Thymus cancer
Hodgkin disease
Disseminated chronic myeloid leukaemia

 

Clinical presentation

There is typically bilateral swelling of the distal portion of the fingers or toes. The onset is slow and may go unnoticed by the patient. Digital clubbing is generally painless, but some patients report mild discomfort. It is most commonly discovered as part of an examination for other presenting symptoms.

 

Prominent digital clubbing Wikipedia
Courtesy of Desherinka CC BY-SA 4.0

 

As clubbing progresses, The Lovibond angle (the angle between the nail and the nail base) becomes obliterated. The Lovibond angle is less than or equal to 160° in normal circumstances. With increasing convexity of the nail, the angle becomes greater than 180°. In the early stages of 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 the presence of digital clubbing, this window is obliterated, and the distal angle formed by the two nails becomes wider. This is known as Schamroth’s window test.

 

A normal Samoroth’s window test in a patient without digital clubbing

 

Grading

Digital clubbing is graded as follows:

GradeDescription
Grade 1Fluctuation or softening of the nail bed
Grade 2Increase in the Lovibond angle to greater than 160°
Grade 3Accentuated convexity of the nail
Grade 4Clubbed appearance of the fingertip
Grade 5Development of a shiny or glossy change in the nail and adjacent skin with longitudinal striations

 

 


Thank you to the joint editorial team of www.plabprep.co.uk for this ‘Exam Tips’ post.

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