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E-mail: moc. This article has been cited by other articles in PMC. Abstract Digital clubbing is an ancient and important clinical signs in medicine. Although clubbed fingers are mostly asymptomatic, it often predicts the presence of some dreaded underlying diseases. Its exact pathogenesis is not known, but platelet-derived growth factor and vascular endothelial growth factor are recently incriminated in its causation.
The association of digital clubbing with various disease processes and its clinical implications are discussed in this review. It results in increase in both anteroposterior and lateral diameter of the nails. It was first described by Hippocrates[ 2 ] nearly years ago in a patient with empyema. Because of this, it is often described as Hippocratic finger and is regarded to be the oldest sign in clinical medicine.
Although clubbed fingers are mostly asymptomatic, it often reflects the presence of dreadful internal illness like lung cancer, idiopathic pulmonary fibrosis, or underlying suppurative conditions. Digital clubbing may occur as isolated finding or is often part of the syndrome of hypertrophic osteoarthropathy HOA which is characterized by periostosis of the long bones and occasional painful joint enlargement.
It was initially known as hypertrophic pulmonary osteoarthropathy HPOA based on the fact that majority of cases of HOA are due to malignant thoracic tumors. In the later condition, it is known as primary hypertrophic osteoarthropathy PHO or pachydermoperiostotis. It is characterized by digital clubbing, subperiosteal new bone formation, mainly from the ends of long bones, acro-osteolysis, hypertrophy of soft tissues and glands, particularyly in the face and scalp resulting in wrinkling of skin on the face and scalp.
On palpation, it gives a spongy sensation. Eventually, the depth of distal phalanx increases and distal inter-phalangeal joint may become hyper-extensible. At this stage, finger develops a clubbed appearance. Finally, the nail and peri-ungual skin appear shiny and nail develops longitudinal ridging.
This whole process usually takes years but in certain conditions, clubbing may develop sub-acutely e. Although different grading of clubbing has been described, it has no clinical significance. Table 1 Open in a separate window Clubbing may be associated with various clinical conditions [ Table 2 ]; however, lung diseases are most commonly associated with clubbing and neoplastic lung disease is the most common pulmonary cause of clubbing.
Other lung diseases that can be associated with clubbing are bronchiectasis, lung abscess, interstitial lung disease, fibrous pleural tumors, mesothelioma, etc. Other diseases are cardiac conditions namely, cyanotic heart diseases, infective endocarditis and gastrointestinal diseases namely, inflammatory bowel disease, coeliac disease, cirrhosis mostly primary biliary cirrhosis.
There are also cases of congenital and idiopathic clubbing, and pseudo-clubbing. However, contrary to this classical view, Findik and Baughman et al. Most studies did notice a male predominance of clubbing in lung cancer patients[ 26 ] except Sridhar et al. Hirakata et al. There are few case reports of digital clubbing occurrence in malignant mesothelioma, pleural fibroma, and metastatic osteogenic sarcoma.
The incidence of clubbing in malignant pleural mesothelioma is high enough to be included in the list of digital clubbing. Solitary fibrous tumor of pleura is less common than malignant mesothelioma.
Moreover, they are mesenchymal in origin unlike mesothelial origin of mesothelioma. They often develop characteristic paraneoplastic syndrome of clubbing, HOA, and hypoglycemia, not typically seen with mesothelioma. Vandemergel et al.
Pulmonary metastases from extrathoracic neoplasms are rare cause of clubbing and HPOA. Most of the reported cases have been sarcomas, mainly of bone and soft tissues; among the rest are tumors of the nasopharynx and uterus and cervix and renal cell carcinoma. Characteristically, clubbing is mainly seen in the presence of intrathoracic involvement and in children and adolescents.
Kanematsu et al. It is more commonly noted among male patients. Ryu et al. Asbestosis is another ILD where clubbing is commonly seen. Coutts et al. However, its association with secondary HOA has been very rarely found. Kittis et al. Collins et al. There is also a possibility that mucosal inflammatory changes and fibrosis in the gut may act as focal stimuli for vagus nerve and possibly other autonomic nerve, acting as the afferent arc of a finger clubbing reflex.
Vasculitis of digital vasculature by impairing endothelial functions promote platelet aggregation and may cause clubbing. Digital clubbing is mainly reported in biliary cirrhosis[ 52 ] but has also been described in other liver diseases,[ 53 ] such as portal cirrhosis,[ 54 ] secondary hepatic amyloidosis, alcoholic cirrhosis, and biliary atresia.
It is characterized by clubbing and swelling of the fingers and toes, with or without periosteal reaction of the distal bones. Only few case reports are there linking HIV infection and clubbing. However, direct linking of HIV to clubbing is still a matter of controversy. In an observational study, Dever et al. Patients with digital clubbing are slightly younger in age and had history of longer duration of HIV infection. Clubbing in HIV-infected patients has generally been attributed to concomitant pulmonary infection.
Ddungu et al. Henry et al. Unilateral clubbing is usually associated with local vascular lesions of the arm, axilla, and thoracic outlet and with hemiplegia. It may be explained by the different methods use to elicit clubbing. Incidence of clubbing increases with the duration of stroke and Siragusa noticed development of clubbing months after the stroke. Hypertrophy and edema of the soft tissues may be responsible for the obliteration of the nail angle in hemiplegic patients.
Several theories have been put forward to explain it. Occasionally, clubbing may occur selectively in lower limbs, sparing the upper limbs. This is known as differential clubbing. Differential clubbing may occur in patient with patent ductus arteriosus associated with pulmonary artery hypertension and right to left shunt.
In this condition, deoxygenated blood from the right ventricle enters aorta distal to the origin of left subclavian artery, thereby sparing the upper extremities. It may also occur in infected abdominal aortic aneurysm. Chronic obstructive pulmonary disease COPD per se does not cause clubbing, but if clubbing is present in COPD, underlying lung cancer and bronchiectasis must be ruled out.
However, it is subjective and often unreliable, particularly in mild cases. It was objectively measured by material brass templates[ 80 ] with arcs of various sizes, plethysmography,[ 81 ] digital casts,[ 82 ] and shadowgraph[ 83 ] technique. All these methods are relatively crude and cannot be accepted as standard as they do not provide easy quantification.
Recently, digital cameras and computerized analysis[ 1 ] have been used to objectively assess clubbing. It is an easy, rapid and relatively inexpensive method to study finger clubbing.
It is defined by the angle made by nail as it exists from the proximal nail fold. Hyponychial angle It is constructed by drawing a line from distal digital crease to the cuticle and another line from the cuticle to hyponychium which is the thickened stratum corneum of epidermis lying under the free edge of the nail. It also correlates strikingly with the subjective assessment of clubbing.