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Clubbing
Other names
Drumstick fingers, digital clubbing, watch-glass nails[1]
Clubbing
Specialty
Pulmonology
Nail clubbing, also known as digital clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs.[2][3] Clubbing for no obvious reason can also occur, but is rare.[4][5] Hippocrates was the first to formally document clubbing as a sign of disease, and the phenomenon is therefore occasionally called "Hippocratic fingers".
Contents
1Causes
1.1Isolated clubbing
1.2HPOA
1.3Primary HPOA
2Pathophysiology
3Diagnosis
3.1Detection
4Epidemiology
5See also
6References
7External links
Causes
Isolated clubbing
Clubbing is associated with:
Lung disease:
Lung cancer, mainly non-small-cell (54% of all cases), not seen frequently in small-cell lung cancer (< 5% of cases)[6]
Interstitial lung disease most commonly idiopathic pulmonary fibrosis
Congenital cyanotic heart disease (most common cardiac cause)
Subacute bacterial endocarditis
Atrial myxoma (benign tumor)
Tetralogy of Fallot
Gastrointestinal and hepatobiliary:
Malabsorption
Crohn's disease and ulcerative colitis
Cirrhosis, especially in primary biliary cirrhosis[7]
Hepatopulmonary syndrome, a complication of cirrhosis[8]
Others:
Graves' disease (autoimmune hyperthyroidism) – in this case it is known as thyroid acropachy[9]
Familial and racial clubbing and "pseudoclubbing" (people of African descent often have what appears to be clubbing)
Vascular anomalies of the affected arm such as an axillary artery aneurysm (in unilateral clubbing)
Nail clubbing is not specific to chronic obstructive pulmonary disease (COPD). Therefore, in patients with COPD and significant degrees of clubbing, a search for signs of bronchogenic carcinoma (or other causes of clubbing) might still be indicated.[10]
A congenital form has also been recognized.[11]
HPOA
Main article: Periosteal reaction
Bone scan of a patient with HPOA
A special form of clubbing is hypertrophic pulmonary osteoarthropathy, known in continental Europe as Pierre Marie-Bamberger syndrome. This is the combination of clubbing and thickening of periosteum (connective tissue lining of the bones) and synovium (lining of joints), and is often initially diagnosed as arthritis. It is commonly associated with lung cancer.[citation needed]
Primary HPOA
Primary hypertrophic osteoarthropathy is HPOA without signs of pulmonary disease. This form has a hereditary component, although subtle cardiac abnormalities can occasionally be found. It is known eponymously as the Touraine–Solente–Golé syndrome. This condition has been linked to mutations in the gene on the fourth chromosome (4q33-q34) coding for the enzyme 15-hydroxyprostaglandin dehydrogenase (HPGD); this leads to decreased breakdown of prostaglandin E2 and elevated levels of this substance.[12]
Pathophysiology
The exact cause for sporadic clubbing is unknown, with numerous theories as to its cause. Vasodilation (i.e., distended blood vessels), secretion of growth factors (e.g., platelet-derived growth factor and hepatocyte growth factor) from the lungs, and other mechanisms have been proposed. The discovery of disorders in the prostaglandin metabolism in primary osteoarthropathy has led to suggestions that overproduction of PGE2 by other tissues may be the causative factor for clubbing.[12]
Another mechanism by which clubbing is thought to arise from is due to increased entry of megakaryocytes into the systemic circulation. Under normal circumstances in healthy individuals, megakaryocytes that arise from the bone marrow are trapped in the pulmonary capillary bed and broken down before they enter the systemic circulation. It is thought that in disorders where there is right-to-left shunting or lung malignancy, the megakaryocytes can bypass the breakdown within the pulmonary circulation and enter the systemic circulation. They are then trapped within the capillary beds within the extremities, such as the digits, and release platelet-derived growth factor (PDGF) and vascular endothelial growth factor (VEGF). PDGF and VEGF have growth promoting properties and cause connective tissue hypertrophy and capillary permeability.[13]
Diagnosis
Clubbing of the fingernail: The red line shows the outline of a clubbed nail.
When clubbing is encountered in patients, doctors will seek to identify its cause and exclude pseudoclubbing before making the diagnosis. They usually accomplish this by obtaining a detailed medical history—particular attention is paid to lung, heart, and gastrointestinal conditions—and conducting a thorough clinical examination, which may disclose associated features relevant to the underlying diagnosis. Additional studies such as a chest X-ray and a chest CT-scan may also be performed.[10]
Detection
Clubbing may be present in one of five stages:[10]
No visible clubbing - Fluctuation (increased ballotability) and softening of the nail bed only. No visible changes of nails.
Mild clubbing - Loss of the normal <165° angle (Lovibond angle) between the nailbed and the fold (cuticula). Schamroth's window (see below) is obliterated. Clubbing is not obvious at a glance.
Moderate clubbing - Increased convexity of the nail fold. Clubbing is apparent at a glance.
Gross clubbing - Thickening of the whole distal (end part of the) finger (resembling a drumstick)
Hypertrophic osteoarthropathy - Shiny aspect and striation of the nail and skin
Schamroth's test or Schamroth's window test (originally demonstrated by South African cardiologist Leo Schamroth on himself)[14] is a popular test for clubbing. When the distal phalanges (bones nearest the fingertips) of corresponding fingers of opposite hands are directly opposed (place fingernails of same finger on opposite hands against each other, nail to nail), a small diamond-shaped "window" is normally apparent between the nailbeds. If this window is obliterated, the test is positive and clubbing is present.
Severe clubbing
Front view
Side views
Cyanotic nail beds
Epidemiology
The exact frequency of clubbing in the population is not known. A 2008 study found clubbing in 1%, or 15 patients, of 1511 patients admitted to a department of internal medicine in Belgium. Of these, 40%, or 6 patients, turned out to have significant underlying disease of various causes, while 60%, or 9 patients, had no medical problems on further investigations and remained well over the subsequent year.[5]
See also
Clubbed thumb (unrelated congenital deformity)
References
^Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1.
^Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0. :656
^Schwatz, RA. "Clubbing of the Nails". Medscape. Medscape. Retrieved 14 August 2014.
^ abVandemergel X, Renneboog B (July 2008). "Prevalence, aetiologies and significance of clubbing in a department of general internal medicine". Eur. J. Intern. Med. 19 (5): 325–9. doi:10.1016/j.ejim.2007.05.015. PMID 18549933.
^Sridhar KS, Lobo CF, Altman RD (1998). "Digital clubbing and lung cancer". Chest. 114 (6): 1535–37. doi:10.1378/chest.114.6.1535. PMID 9872183. Archived from the original (PDF) on 2003-11-01.
^Epstein O, Dick R, Sherlock S (1981). "Prospective study of periostitis and finger clubbing in primary biliary cirrhosis and other forms of chronic liver disease". Gut. 22 (3): 203–6. doi:10.1136/gut.22.3.203. PMC 1419499. PMID 7227854.
^Naeije R (March 2003). "Hepatopulmonary syndrome and portopulmonary hypertension". Swiss Med Wkly. 133 (11–12): 163–9. PMID 12715285.
^"acropachy". GPnotebook.
^ abcMyers KA, Farquhar DR (2001). "The rational clinical examination: does this patient have clubbing?". JAMA. 286 (3): 341–7. doi:10.1001/jama.286.3.341. PMID 11466101.
^Shah K, Ferrara TM, Jan A, Umair M, Irfanullah, Khan S, Ahmad W, Spritz RA (August 2017). "Homozygous SLCO2A1 translation initiation codon mutation in a Pakistani family with recessive isolated congenital nail clubbing". Br. J. Dermatol. 177 (2): 546–548. doi:10.1111/bjd.15094. PMID 27681482.
^ abUppal S, Diggle CP, Carr IM, et al. (June 2008). "Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy". Nat. Genet. 40 (6): 789–93. doi:10.1038/ng.153. PMID 18500342.
^Dickinson, CJ; Martin, JF (19 December 1987). "Megakaryocytes and platelet clumps as the cause of finger clubbing". Lancet. 2 (8573): 1434–5. PMID 2891996.
^Schamroth L (February 1976). "Personal experience". S. Afr. Med. J. 50 (9): 297–300. PMID 1265563.
External links
Classification
D
ICD-10: R68.3
ICD-9-CM: 781.5
MeSH: M0015512 D010005, M0015512
v
t
e
Disorders of skin appendages (L60–L75, 703–706)
Nail
thickness: Onychogryphosis
Onychauxis
color: Beau's lines
Yellow nail syndrome
Leukonychia
Azure lunula
shape: Koilonychia
Nail clubbing
behavior: Onychotillomania
Onychophagia
other: Ingrown nail
Anonychia
ungrouped: Paronychia
Acute
Chronic
Chevron nail
Congenital onychodysplasia of the index fingers
Green nails
Half and half nails
Hangnail
Hapalonychia
Hook nail
Ingrown nail
Lichen planus of the nails
Longitudinal erythronychia
Malalignment of the nail plate
Median nail dystrophy
Mees' lines
Melanonychia
Muehrcke's lines
Nail–patella syndrome
Onychoatrophy
Onycholysis
Onychomadesis
Onychomatricoma
Onychomycosis
Onychophosis
Onychoptosis defluvium
Onychorrhexis
Onychoschizia
Platonychia
Pincer nails
Plummer's nail
Psoriatic nails
Pterygium inversum unguis
Pterygium unguis
Purpura of the nail bed
Racquet nail
Red lunulae
Shell nail syndrome
Splinter hemorrhage
Spotted lunulae
Staining of the nail plate
Stippled nails
Subungual hematoma
Terry's nails
Twenty-nail dystrophy
Hair
Hair loss/ Baldness
noncicatricial alopecia: Alopecia
areata
totalis
universalis
Ophiasis
Androgenic alopecia (male-pattern baldness)
Hypotrichosis
Telogen effluvium
Traction alopecia
Lichen planopilaris
Trichorrhexis nodosa
Alopecia neoplastica
Anagen effluvium
Alopecia mucinosa
cicatricial alopecia: Pseudopelade of Brocq
Central centrifugal cicatricial alopecia
Pressure alopecia
Traumatic alopecia
Tumor alopecia
Hot comb alopecia
Perifolliculitis capitis abscedens et suffodiens
Graham-Little syndrome
Folliculitis decalvans
ungrouped: Triangular alopecia
Frontal fibrosing alopecia
Marie Unna hereditary hypotrichosis
Hypertrichosis
Hirsutism
Acquired
localised
generalised
patterned
Congenital
generalised
localised
X-linked
Prepubertal
Acneiform eruption
Acne
Acne vulgaris
Acne conglobata
Acne miliaris necrotica
Tropical acne
Infantile acne/Neonatal acne
Excoriated acne
Acne fulminans
Acne medicamentosa (e.g., steroid acne)
Halogen acne
Iododerma
Bromoderma
Chloracne
Oil acne
Tar acne
Acne cosmetica
Occupational acne
Acne aestivalis
Acne keloidalis nuchae
Acne mechanica
Acne with facial edema
Pomade acne
Acne necrotica
Blackhead
Lupus miliaris disseminatus faciei
Rosacea
Perioral dermatitis
Granulomatous perioral dermatitis
Phymatous rosacea
Rhinophyma
Blepharophyma
Gnathophyma
Metophyma
Otophyma
Papulopustular rosacea
Lupoid rosacea
Erythrotelangiectatic rosacea
Glandular rosacea
Gram-negative rosacea
Steroid rosacea
Ocular rosacea
Persistent edema of rosacea
Rosacea conglobata
variants
Periorificial dermatitis
Pyoderma faciale
Ungrouped
Granulomatous facial dermatitis
Idiopathic facial aseptic granuloma
Periorbital dermatitis
SAPHO syndrome
Follicular cysts
"Sebaceous cyst"
Epidermoid cyst
Trichilemmal cyst
Steatocystoma
simplex
multiplex
Milia
Inflammation
Folliculitis
Folliculitis nares perforans
Tufted folliculitis
Pseudofolliculitis barbae
Hidradenitis
Hidradenitis suppurativa
Recurrent palmoplantar hidradenitis
Neutrophilic eccrine hidradenitis
Ungrouped
Acrokeratosis paraneoplastica of Bazex
Acroosteolysis
Bubble hair deformity
Disseminate and recurrent infundibulofolliculitis
Erosive pustular dermatitis of the scalp
Erythromelanosis follicularis faciei et colli
Hair casts
Hair follicle nevus
Intermittent hair–follicle dystrophy
Keratosis pilaris atropicans
Kinking hair
Koenen's tumor
Lichen planopilaris
Lichen spinulosus
Loose anagen syndrome
Menkes kinky hair syndrome
Monilethrix
Parakeratosis pustulosa
Pili (Pili annulati
Pili bifurcati
Pili multigemini
Pili pseudoannulati
Pili torti)
Pityriasis amiantacea
Plica neuropathica
Poliosis
Rubinstein–Taybi syndrome
Setleis syndrome
Traumatic anserine folliculosis
Trichomegaly
Trichomycosis axillaris
Trichorrhexis (Trichorrhexis invaginata
Trichorrhexis nodosa)
Trichostasis spinulosa
Uncombable hair syndrome
Wooly hair
Wooly hair nevus
Sweat glands
Eccrine
Miliaria
Colloid milium
Miliaria crystalline
Miliaria profunda
Miliaria pustulosa
Miliaria rubra
Occlusion miliaria
Postmiliarial hypohidrosis
Granulosis rubra nasi
Ross’ syndrome
Anhidrosis
Hyperhidrosis
Generalized
Gustatory
Palmoplantar
Apocrine
Body odor
Chromhidrosis
Fox–Fordyce disease
Sebaceous
Sebaceous hyperplasia
v
t
e
Symptoms and signs: nervous and musculoskeletal systems (R25–R29, 781.0, 781.2–9)
Primarily nervous system
Primarily CNS
Movement disorders
Dyskinesia: Athetosis
Tremor
Gait abnormality
Scissor gait
Cerebellar ataxia
Festinating gait
Marche à petit pas
Propulsive gait
Stomping gait
Spastic gait
Magnetic gait
Truncal ataxia
Lack of coordination
Dyskinesia: Ataxia
Cerebellar ataxia/Dysmetria
Sensory ataxia
Dyssynergia
Dysdiadochokinesia
Asterixis
Other
Abnormal posturing: Opisthotonus
Sensory processing disorder: Hemispatial neglect
Facial weakness
Hyperreflexia
Pronator drift
Primarily PNS
Gait abnormality
Steppage gait
Antalgic gait
Primarily muscular
Movement disorders
Spasm
Trismus
Fasciculation
Fibrillation
Myokymia
Cramp
Gait abnormality
Myopathic gait
Trendelenburg gait
Pigeon gait
Other
Tetany
Meningism
Primarily skeletal
Rachitic rosary
Clubbing
Primarily joint
Joint locking
v
t
e
Symptoms and signs relating to the respiratory system (R04–R07, 786)
Medical examination and history taking
Auscultation
Stethoscope
Respiratory sounds
Stridor
Wheeze
Crackles
Rhonchi
Stertor
Squawk
Pleural friction rub
Fremitus
Bronchophony
Terminal secretions
Elicited findings
Percussion
Pectoriloquy
Whispered pectoriloquy
Egophony
Breathing
Rate
Apnea
Prematurity
Dyspnea
Hyperventilation
Hypoventilation
Hyperpnea
Tachypnea
Hypopnea
Bradypnea
Pattern
Agonal respiration
Biot's respiration
Cheyne–Stokes respiration
Kussmaul breathing
Ataxic respiration
Other
Respiratory distress
Respiratory arrest
Orthopnea/Platypnea
Trepopnea
Aerophagia
Asphyxia
Breath holding
Mouth breathing
Snoring
Other
Chest pain
In children
Precordial catch syndrome
Pleurisy
Nail clubbing
Cyanosis
Cough
Sputum
Hemoptysis
Epistaxis
Silhouette sign
Post-nasal drip
Hiccup
COPD
Hoover's sign
asthma
Curschmann's spirals
Charcot–Leyden crystals
chronic bronchitis
Reid index
sarcoidosis
Kveim test
pulmonary embolism
Hampton hump
Westermark sign
pulmonary edema
Kerley lines
Hamman's sign
Golden S sign
v
t
e
Medical examination and history taking
Medical history
Chief complaint
History of the present illness
Systems review
Nursing assessment
Allergies
Medications
Past medical history
Family history
Social history
Psychiatric history
Progress notes
Mnemonics
SAMPLE
OPQRST
SOAP
COASTMAP
Physical examination
General/IPPA
Inspection
Auscultation
Palpation
Percussion
Vital signs
Temperature
Heart rate
Blood pressure
Respiratory rate
HEENT
Oral mucosa
TM
Eyes (Ophthalmoscopy, Swinging-flashlight test)
Hearing (Weber, Rinne)
Respiratory
Respiratory sounds
Cyanosis
Clubbing
Cardiovascular
Precordial examination
Peripheral vascular examination
Heart sounds
Other
Jugular venous pressure
Abdominojugular test
Carotid bruit
Ankle-brachial pressure index
Abdominal
Digestive
Liver span
Rectal
Murphy's sign
Bowel sounds
Urinary
Murphy's punch sign
Extremities/Joint
Back (Straight leg raise)
Knee (McMurray test)
Hip
Wrist (Tinel sign, Phalen maneuver)
Shoulder (Adson's sign)
GALS screen
Neurological
Mental state
Mini–mental state examination
Cranial nerve examination
Upper limb neurological examination
Neonatal
Apgar score
Ballard Maturational Assessment
Gynecological
Well-woman examination
Vaginal examination
Breast examination
Cervical motion tenderness
Assessment and plan
Medical diagnosis
Differential diagnosis
UpToDate Contents
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… The basic clinically relevant anatomy of the fingers and thumb is reviewed here. Specific finger injuries and their management are discussed elsewhere. Finger function involves a complex interaction among …
… distal phalanx. Less frequently, a mallet finger may occur as part of finger injuries involving dorsal lacerations or crushing mechanisms. With mallet finger injuries, the tendon may be partially torn …
… manifestations, diagnosis and treatment of trigger finger are discussed here. The anatomy of the finger flexion and pulley system is reviewed separately. Trigger finger is one of the most common causes of hand …
… sprained finger, but requires more urgent management than these minor injuries. The mechanism, diagnosis, and management of jersey finger will be reviewed here. The management of other finger injuries …
…the nails. Typically, the nails of the fingers lie in the same transverse axis. Any change in orientation of the nail of one finger relative to the adjacent fingers suggests rotational displacement. In uncooperative …
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… Consequently, energy demanded of skilled group was significantly lower than that of unskilled group at 480 beats/min. Then the vertical displacement of the center of gravity concerning both upper limb and drumstick of skilled group was significantly smaller. … And, on both skilled and unskilled groups, after the center of gravity of drumstick reached its highest point, drumstick tip reached its highest point, successively; …
Looking for online definition of drumstick finger in the Medical Dictionary? drumstick finger explanation free. What is drumstick finger? Meaning of drumstick finger medical term. What does drumstick finger mean? https://medical ...
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