Clinical ReviewClubbing: An update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance
Section snippets
Clinical
Researchers have described many techniques for the accurate diagnosis of clubbing. Recognizing that the presence or absence of clubbing was not always obvious at the bedside, Lovibond43 was among the first to offer a criteria for the diagnosis of finger clubbing. Lovibond43 defined the “profile sign” of the thumb, or Lovibond's angle as it came to be known, as the angle made by the nail as it exits the proximal nailfold. He reported that a profile sign of greater than 180 degrees could be used
Differential diagnosis
Many diseases have been associated with secondary clubbing with or without HOA. Table I, Table II provide an overview.
Pathophysiology
Numerous hypotheses of the pathophysiology of clubbing have been proposed over the years. One group proposed a neurocirculatory reflex based on a patient with an ulnar artery aneurysm and subsequent ipsilateral finger clubbing.58 The authors hypothesized that clubbing is associated with local arteriovenous anastamoses provoked by alterations in vascular dynamics that allow blood to bypass capillaries; these anastamoses are actually neurohumoral end organs that allow the autonomic nervous system
Evaluation
In evaluating a patient with new-onset clubbing, it is first important to verify that the patient has true clubbing and not pseudoclubbing. Pseudoclubbing usually involves only a single digit. The digit may appear at first glance to be truly clubbed but, on closer inspection, the profile angle will likely be normal. Pseudoclubbing of a single digit can be seen in patients with a subungual tumor,68 pseudocyst,69 or osteoid osteoma.70 Generalized pseudoclubbing can be seen in disease processes
Prognosis and treatment
Clubbing has been studied widely as a prognostic factor. It has been suggested that its presence can be used to distinguish idiopathic pulmonary fibrosis from pulmonary fibrosis secondary to collagen vascular disease.77 In cystic fibrosis,78, 79 asbestosis,35 hypersensitivity pneumonitis,36 tuberculosis,80 and idiopathic pulmonary fibrosis,81 clubbing has been associated with greater severity of disease or increased risk of mortality.
The prognosis of clubbing is completely dependent on the
References (83)
Paraneoplastic digital clubbing and hypertrophic osteoarthropathy
Clin Dermatol
(1993)- et al.
Finger clubbing in malignant mesothelioma and benign asbestos pleural disease
Respir Med
(1998) - et al.
Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997
Mayo Clin Proc
(1999) - et al.
Hepatopulmonary syndrome in candidates for liver transplantation
J Hepatol
(2001) - et al.
Sarcoidosis in India
Br J Dis Chest
(1985) - et al.
10 years of infective endocarditis at St Bartholomew's Hospital: analysis of clinical features and treatment in relation to prognosis and mortality
Lancet
(1980) - et al.
Pulmonary disease in children with acquired immune deficiency syndrome and AIDS-related complex
J Pediatr
(1986) - et al.
POEMS syndrome: definitions and long-term outcome
Blood
(2003) Diagnosis of clubbed fingers
Lancet
(1938)- et al.
Subjective assessment and objective measurement of finger clubbing
Lancet
(1967)
An improved method of studying fingernail morphometry: application to the early detection of finger clubbing
J Am Acad Dermatol
The pathology of clubbing: vascular changes in the nail bed
Br J Dis Chest
Digital clubbing: demonstration with positron emission tomography
Chest
Digital clubbing: a unique case and a new hypothesis
J Hand Surg
Megakaryocytes and platelet clumps as the cause of finger clubbing
Lancet
Association between platelet microthrombi and finger clubbing
Lancet
Unilateral finger clubbing
Lancet
Cutaneous paraneoplastic syndromes in solid tumors
Am J Med
The importance of finger clubbing in pulmonary tuberculosis
Tubercle
Clubbing of the fingers and smooth muscle proliferation in fibrotic changes in the lung in patients with idiopathic pulmonary fibrosis
Chest
Nail disorders
Hypertrophic osteoarthropathy: consensus on its definition, classification, assessment, and diagnostic criteria
J Rheumatol
The clinical spectrum of pachydermoperiostosis (primary hypertrophic osteoarthropathy)
Medicine (Baltimore)
Familial clubbing of the fingers and toes
BMJ
Unilateral clubbing of the fingernails in patients with hemiplegia
Gerontol Clin
Nail pathology in patients with hemiplegia
Br J Dermatol
Clubbing secondary to an arteriovenous fistula used for hemodialysis
JAMA
Takayasu's arteritis presenting with unilateral digital clubbing
J Rheumatol
Palmar aneurysm accompanied by ipsilateral clubbing finger: a case report
Angiology
Digital clubbing and cancer
Chest
Solitary fibrous tumor of the pleura
Eur J Cardiothorac Surg
Primary upper small-intestinal lymphoma: a report of 40 cases from Iran
Dig Dis
Hypertrophic osteoarthropathy and intrathoracic Hodgkin disease of childhood
Med Pediatr Oncol
Clinical features and management of distant metastases of nasopharyngeal carcinoma
J Otolaryngol
Finger clubbing in cystic fibrosis
Arch Dis Child
Significance of finger clubbing in asbestosis
Thorax
Clubbing in hypersensitivity pneumonitis: its prevalence and possible prognostic role
Arch Intern Med
British Thoracic Society study of cryptogenic fibrosing alveolitis: current presentation and initial management
Thorax
Hypertrophic osteoarthropathy associated with cyanotic congenital heart disease
Ann Intern Med
Finger clubbing in inflammatory bowel disease: its prevalence and pathogenesis
BMJ
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2021, Dermatologic ClinicsCitation Excerpt :If it exceeds 1, clubbing is confirmed (see Fig. 2).31 Clubbing can be congenital (associated or not with various genetic syndromes) or acquired and unilateral or bilateral.27,28 It can be isolated or occur as part of the hypertrophic osteoarthropathy syndrome, characterized by periostosis of long bones, arthralgia, and clubbing.27,28
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Conflicts of interest: None identified.