FINGER CLUBBING

History
 Lung conditions (bronchogenic carcinoma; fibrosing alveolitis; mesothelioma; suppurative lung disease such as
bronchiectasis, lung abscess and empyema)
 Cardiac conditions (infective endocarditis, cyanotic heart disease)
 GI tract conditions (cirrhosis, ulcerative colitis, Crohn’s disease)
 Thyroid disease (thyroid acropachy)
 Family history (hereditary clubbing).

Examination
 Increased curvature of the nails, obliteration of the angle of the nail. A positive Schamroth test is the absence of
the normal diamond-shaped window created when the dorsal surfaces of the terminal phalanges of similar fingers
are opposed.
 When in doubt, approximate the dorsal aspects of terminal phalanges of the fingers of both hands flexed at the
interphalangeal joints. Normally, the angle between the nails does not extend more than halfway up the nail bed.
In clubbing there is a wide and deep angle, Schamroth’s sign.
 Loss of Lovibond’s angle:

 The nails may have a drumstick appearance

  Proceed as follows:
► Look for the following signs:
a. Fluctuation at the nail bed
b. Nicotine (tar) staining of fingers
c. Central cyanosis
d. Clubbing of the toes.
► Palpate the wrist joints for tenderness: hypertrophic pulmonary osteoarthropathy
(HPOA); rapid painful clubbing is nearly always caused by bronchogenic carcinoma.
► The following systems should be examined
1. Chest: bronchogenic carcinoma; fibrosing alveolitis; mesothelioma; suppurative
lung disease such as bronchiectasis, lung abscess and empyema
2. Heart: infective endocarditis, cyanotic heart disease; in infective endocarditis the
fingers may be pale and their tips flushed (‘pale hands, pink tipped’)
3. GI: cirrhosis, ulcerative colitis, Crohn’s disease
4. Thyroid: thyroid acropachy; ~20% of patients with thyroid dermopathy have thyroid
acropachy, which manifests as clubbing of the fingers and toes.

 Grade of clubbing:
► Grade I: increased glossiness and cyanosis of the skin at the root of the nail associated
with increased fluctuation at the base of the nail bed
► Grade II: the normal angle between the base of the nail and the skin is obliterated
(Lovibond’s sign) and may even be reversed
► Grade III: hypertrophy of the soft tissue of the nail pulp and the nail curves excessively
longitudinally to give a ‘drum-stick’ or ‘parrot-beak’ appearance.
► Grade IV: bony changes involving the wrists and ankles, sometimes the elbows and
knees (HPOA).