Clubbing is a term that describes the absence of the normal angle between the nail plate and the nailbed, as well as the nailbed’s boggy volatility. At the base of the nailbed, the finger’s depth equals or exceeds that of the distal interphalangeal joint. In severe instances, the curve of the nail increases from top to bottom, as well as swelling or expansion of the posterior portion of the finger, presenting the resemblance of a drumstick. The reason behind this is an increase in connective tissue due to a change in prostaglandin metabolism.This condition is also known as Hippocratic nails.
The following clinical techniques can be used to demonstrate clubbing in uncertain cases:
- The depth of the nail at the base is usually less than the depth at the distal interphalangeal joint. Digital clubbing is present if it reaches an equivalent or greater level. This is said to be the most effective way to monitor clubbing.
- Schamroth (Diamond) sign. A diamond, or rhomboid-shaped window, is normally left out when we estimate the nails of two fingers. The absence of a window implies the presence of clubbing. Even little clubbing has a high sensitivity to this indicator. The increase in the number of soft tissues under the base of the nails is the problem causing the window’s depletion.
- Lovibond’s profile sign. From 160° to 7180°, the angle between the curved nail plate and the proximal nail fold (viewed from the lateral side) has been increased.
- Curth’s modified profile sign. At the interphalangeal joint, the angle between the middle phalanx and the terminal phalanx is lowered from 180° to 160°.
- Fluctuation sign. Clubbing can also be triggered by rocking the examiner’s index finger and thumb over the nail’s bed. It appears to be floating.
Clubbing is a common sign of bronchiectasis, which can be caused by TB, congenital bronchial or bronchiole defects, neglected aspiration of foreign material, or chronic/recurrent chest infection in the context of a condition such as cystic fibrosis, ciliary dyskinesia, or an immune system abnormality. Chronic cough with purulent sputum, foul-smelling breath (halitosis), recurrent chest infection, and failure to thrive are among some of the symptoms. Wheeze and crepitations are prevalent auscultatory indications, which might be localised or widespread owing to a foreign body (cystic fibrosis).
When anemia as well as other indications of malnutrition exist side by side with long-term empyema, clubbing emerges. The symptoms of pneumonia are present predominantly; however, they may be non-existent. Reduced mobility on the afflicted side, expansion and dullness of the intercostal gaps (even edema), dull percussion tone, decreased air intake, and a transfer of the mediastinum to the opposite side are all indicators of chest abnormalities. A diagnostic pleural tap is required to be conducted in addition to a chest X-ray.
When a patient with a persistent lung abscess goes without therapy for an extended period of time, clubbing might occur. Fever, a persistent cough, and foul-smelling sputum are common symptoms of the disease’s onset. Dyspnea and chest discomfort are both possible side effects. Consolidation of the chest with bronchial breathing is the most common sign. The X-ray of the chest reveals classic opacities, as well as fluid levels in the cavities.
A subset of children having progressive pulmonary Tuberculosis, particularly fibrocaseous tuberculosis, tends to have substantial clubbing.
Clubbing in the presence of severe malnutrition despite a healthy appetite and food intake, recurrent diarrhea, and repeated chest infections from early childhood may involve consideration of cystic fibrosis. Steatorrhea is a pancreatogenous condition. The diagnosis is confirmed by the presence of elevated sweat chloride levels (more than 60 mEq/L).
Other Pulmonary Causes
Alveolar proteinosis, alveolar-capillary block syndrome, Hammen-Rich syndrome, chronic fibrosing alveolitis, emphysema, chronic pneumonia, mesothelima, and bronchus malignancy are all examples of pulmonary alveolar proteinosis. These are some of the other causes of pulmonary insufficiency.
Infective endocarditis is indicated by clubbing, which is frequently accompanied by pea-sized painful swellings in the pulp of the fingers and toes (Osler nodes) and splinter hemorrhages underlying the nails. Also prevalent are anemia, splenomegaly, low-grade fever, and microscopic hematuria. Positive blood cultures are obtained every 6 hours for 36 hours to confirm the diagnosis, and in advanced instances, echocardiography is used to demonstrate the vegetation. Rheumatic or congenital cardiac disease is often the underlying cause.
Cyanotic Congenital Heart Disease
By the age of six months, the child with transposition of the great arteries (TGV) generally develops clubbing. It takes about two years for clubbing to become obvious in Tetralogy of Fallot (TOF).
Some children with substantial steatorrhea, such as celiac disease, tropical sprue, gross protein-energy malnutrition, iron-deficiency anemia, and ancylostomiasis, may experience clubbing.
The extraintestinal indications of ulcerative colitis, such as arthralgia, erythema nodosum, pyoderma gangrenosa, iritis, hepatitis, peripheral hypoproteinemic edema, phlebitis, and hemolytic anemia, all involve clubbing.
Crohn’s Disease (Regional lleitis)
Extraintestinal symptoms of this inflammatory bowel disease, which is generally defined by segmental transmural involvement of the distal ileum and colon, may include clubbing, as in the case of ulcerative colitis.
Clubbing may occur with painless bright red rectal bleeding in this condition involving the colon, commonly after the age of 3-5 years. Recurrence occurs in 25% of individuals even after surgical removal by sigmoidoscopy. Malignancy may also occur in certain people.
Extrahepatic biliary atresia, cystic fibrosis, and chronic active hepatitis are among the conditions that can cause clubbing.
Other Causes of Clubbing
Additional origins of clubbing include congenital (idiopathic), thyrotoxicosis, and Hodgkin’s lymphoma.