Nail clubbing

2025-07-29T08:52:59Z

2601:647:CE83:4DB0:6165:A28B:6459:89DD: ce

{{Short description|Deformity of the finger or toe nails}}
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{{Infobox medical condition (new)
| name = Clubbing
| synonyms = Drumstick fingers/toes, Hippocratic fingers/toes, digital clubbing, watch-glass nails<ref name="Bolognia">{{cite book |author=Rapini, Ronald P. |author2=Bolognia, Jean L. |author3=Jorizzo, Joseph L. |title=Dermatology: 2-Volume Set |publisher=Mosby |location=St. Louis |year=2007 |isbn=978-1-4160-2999-1 }}</ref>
| image = Dedos con acropaquia.jpg
| caption = Clubbing
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| field = [[Pulmonology]]
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'''Nail clubbing''', also known as '''digital clubbing''' or '''clubbing''', is a deformity of the finger or toe [[Nail (anatomy)|nails]] associated with several diseases, anomalies and defects, some congenital, mostly of the [[heart disease|heart]] and [[lung disease|lungs]].<ref>{{cite journal|last1=Rutherford|first1=JD|title=Digital clubbing |journal=Circulation |date=14 May 2013 |volume=127 |issue=19 |pages=1997–9|pmid=23671180 |doi=10.1161/circulationaha.112.000163|doi-access=free }}</ref><ref name="Fitz2">Freedberg, et al. (2003). ''Fitzpatrick's Dermatology in General Medicine''. (6th ed.). McGraw-Hill. {{ISBN|0-07-138076-0}}. {{rp|656}}</ref> When it occurs together with [[joint effusion]]s, joint pains, and abnormal skin and bone growth it is known as [[hypertrophic osteoarthropathy]].<ref>{{cite book |last1=Krugh |first1=M |last2=Vaidya |first2=PN |title=Osteoarthropathy Hypertrophic |date=January 2019|publisher=StatPearls Publishing|pmid=31082012}}</ref>


Clubbing is associated with [[lung cancer]], lung infections, [[interstitial lung disease]], [[cystic fibrosis]], or [[cardiovascular disease]].<ref name=Stat2019/> Clubbing may also run in families,<ref name=Stat2019/> and occur unassociated with other medical problems.<ref>{{cite web|last1=Schwatz|first1=RA|title=Clubbing of the Nails|url=http://emedicine.medscape.com/article/1105946-overview#showall|website=Medscape|access-date=14 August 2014}}</ref><ref name=Vandemergel>{{cite journal |vauthors=Vandemergel X, Renneboog B |title=Prevalence, aetiologies and significance of clubbing in a department of general internal medicine |journal=Eur. J. Intern. Med. |volume=19 |issue=5 |pages=325–329 |date=July 2008 |pmid=18549933 |doi=10.1016/j.ejim.2007.05.015}}</ref>


Clubbing has been recognized as a sign of disease since the time of [[Hippocrates]].<ref name=Stat2019>{{cite book |last1=Burcovschii |first1=S |last2=Aboeed |first2=A |title=Nail Clubbing |date= 2019 |publisher=StatPearls Publishing|pmid=30969535}}</ref>

==Causes==
Clubbing is associated with
* Lung disease:
** [[Lung cancer]]<ref>{{cite journal | vauthors=Sridhar KS, Lobo CF, Altman RD | title=Digital clubbing and lung cancer | journal=Chest | year=1998 | volume=114 | pages=1535–1537 | pmid=9872183 | doi=10.1378/chest.114.6.1535 | issue=6 | doi-access=free }}</ref>
** [[Interstitial lung disease]] most commonly [[idiopathic pulmonary fibrosis]]
** Complicated [[tuberculosis]]
** Suppurative lung disease: [[lung abscess]], [[empyema]], [[bronchiectasis]], [[cystic fibrosis]]
** [[Mesothelioma]] of the pleura
** [[Sarcoidosis]]
* Heart disease:
** Any disease featuring chronic [[hypoxia (medical)|hypoxia]]
** [[Cyanotic heart defect]] (most common cardiac cause)
** [[Infective endocarditis]]
** [[Atrial myxoma]] (benign tumor)
** Arteriovenous fistula or malformation
* Gastrointestinal and hepatobiliary:
** [[Malabsorption]]
** [[Crohn's disease]] and [[ulcerative colitis]]
** [[Cirrhosis]], especially in [[primary biliary cholangitis]]<ref>{{cite journal |vauthors=Epstein O, Dick R, Sherlock S |title=Prospective study of periostitis and finger clubbing in primary biliary cirrhosis and other forms of chronic liver disease |journal=Gut |volume=22 |issue=3 |pages=203–206 |year=1981 |pmid=7227854 |doi=10.1136/gut.22.3.203 |pmc=1419499}}</ref>
** [[Hepatopulmonary syndrome]], a complication of cirrhosis<ref>{{cite journal | pmid = 12715285 | volume=133 | issue=11–12 | title=Hepatopulmonary syndrome and portopulmonary hypertension |date=March 2003 | author=Naeije R | journal=Swiss Med Wkly | pages=163–169| doi=10.4414/smw.2003.10016 | doi-access=free }}</ref>
* Others:
** [[Graves' disease]] (autoimmune hyperthyroidism) – in this case, it is known as ''thyroid [[acropachy]]''<ref>{{Cite GPnotebook|-724565997|acropachy}}</ref>
** Familial and hereditary 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)
** Primary hypertrophic osteoarthropathy

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.<ref name=Myers/> A congenital form has also been recognized.<ref name="pmid27681482">{{cite journal | vauthors = Shah K, Ferrara TM, Jan A, Umair M, Irfanullah, Khan S, Ahmad W, Spritz RA | title = Homozygous SLCO2A1 translation initiation codon mutation in a Pakistani family with recessive isolated congenital nail clubbing | journal = Br. J. Dermatol. | volume = 177 | issue = 2 | pages = 546–548 | date = August 2017 | pmid = 27681482 | doi = 10.1111/bjd.15094 | s2cid = 28251025 }}</ref>

===Hypertrophic pulmonary osteoarthropathy===
{{main|Periosteal reaction}}
[[File:Marie-Bamberger2.jpg|thumb|right|[[Bone scan]] of a patient with HPOA]]
A special form of clubbing is [[hypertrophic pulmonary osteoarthropathy]] (HPOA), 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|date=April 2018}}

===Primary hypertrophic osteoarthropathy===
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 [[Pachydermoperiostosis|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 (NAD+)|15-hydroxyprostaglandin dehydrogenase]] (HPGD); this leads to decreased breakdown of [[PGE2|prostaglandin E2]] and elevated levels of this substance.<ref name=Uppal>{{cite journal |vauthors=Uppal S, Diggle CP, Carr IM, etal |title=Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy |journal=Nat. Genet. |volume=40 |issue=6 |pages=789–793 |date=June 2008 |pmid=18500342 |doi=10.1038/ng.153|s2cid=23484059 }}</ref>

==Pathogenesis==
The exact cause of sporadic clubbing is unknown. Theories as to its cause include:
* [[Vasodilation]] (i.e., distended blood vessels).{{cn|date=June 2021}}
* Secretion of [[growth factor]]s (e.g., [[platelet-derived growth factor]] and [[hepatocyte growth factor]]) from the lungs.{{cn|date=June 2021}}
* Overproduction of prostaglandin E2 by other tissues.<ref name=Uppal/>
* Increased entry of [[megakaryocyte]]s 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 entering 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.<ref>{{cite journal |last1=Dickinson |first1=CJ |last2=Martin |first2=JF |title=Megakaryocytes and platelet clumps as the cause of finger clubbing. |journal=Lancet |date=19 December 1987 |volume=2 |issue=8573 |pages=1434–1435 |pmid=2891996 |doi=10.1016/s0140-6736(87)91132-9|s2cid=43847925 }}</ref>

==Diagnosis==
[[File:Clubbing.svg|thumb|Clubbing of the fingernail: The red line shows the outline of a clubbed nail.]]
[[File:Schamroths.jpg|thumb|Schamroth's window test, done to identify nail clubbing]]

When clubbing is observed, pseudoclubbing should be excluded before making the diagnosis. Associated conditions may be identified by taking 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 reveal otherwise asymptomatic cardiopulmonary disease.<ref name=Myers/>

===Stages===
Clubbing is present in one of five stages:<ref name=Myers>{{cite journal | vauthors=Myers KA, Farquhar DR | title=The rational clinical examination: does this patient have clubbing? | journal=JAMA | year=2001 | volume=286 | pages=341–347 | pmid=11466101 | doi=10.1001/jama.286.3.341 | issue=3}}</ref>
* '''No visible clubbing''' – Fluctuation (increased ballotability) and softening of the nail bed only. No visible changes in nails.
* '''Mild clubbing''' – Loss of the normal <165° angle (Lovibond angle) between the nailbed and the fold (cuticula). Schamroth's window (see image) 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 [[Anatomical terms of location#Proximal and distal|distal]] (end part of the) finger (resembling a drumstick)
* '''[[Hypertrophic osteoarthropathy]]''' – Shiny aspect and [[wikt:striation|striation]] of the nail and skin

Schamroth's sign or Schamroth's window test (originally demonstrated by South African cardiologist [[Leo Schamroth]] on himself)<ref>{{cite journal |author=Schamroth L |title=Personal experience |journal=S. Afr. Med. J. |volume=50 |issue=9 |pages=297–300 |date=February 1976 |pmid=1265563}}</ref> is a popular test for clubbing. When the distal [[phalanges]] (bones nearest the fingertips) of corresponding fingers of opposite hands are directly [[wikt:opposed|opposed]] (place fingernails of the 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.

<gallery>
File:Clubbing of fingers.jpg|Severe clubbing
Clubbing2.JPG|Front view
Clubbing1.JPG|Side views
CongenitalHeartCase-133.jpg|Cyanotic nail beds
</gallery>

==Epidemiology==
[[File:Dick Ket - Autoportrait.jpg|thumb|Self-portrait by [[Dick Ket]] showing nail clubbing.]]
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, had significant underlying disease of various causes, while 60%, or nine patients, had no medical problems after further investigation and remained well over the subsequent year.<ref name=Vandemergel/>

==History==
At least since the time of [[Hippocrates]], clubbing has been recognized as a sign of disease.<ref name=Stat2019/> The phenomenon has been called "Hippocratic fingers".

The Dutch painter [[Dick Ket]] had nail clubbing, as is seen from his paintings. He had an underlying disease, probably [[dextrocardia]].<ref name=":0">(in Dutch) [https://www.ntvg.nl/system/files/publications/1984124230001a.pdf Dick Ket, een schilder en zijn ziekte] W.H.D. de Haas, Nederlands Tijdschrift voor Geneeskunde, 1984</ref>

==See also==
* [[Clubbed thumb]] (unrelated congenital deformity)

==References==
{{Reflist}}
{{Medical resources
| ICD10 = {{ICD10|R|68|3|r|50}}
| ICD9 = {{ICD9|781.5}}
}}
{{Disorders of skin appendages}}
{{Respiratory system symptoms and signs}}

[[Category:Conditions of the skin appendages]]
[[Category:Symptoms and signs: musculoskeletal system]]

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