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clubbed fingers/toes; clubbing (Hippocratic fingers)

Bulbous enlargement & broadening of the fingertips. Etiology: 1) idiopathic inherited autosomal dominant trait 2) any disease associated with chronic hypoxia 2) cardiac disease a) cyanotic heart disease - lower extermity cyanosis & toe clubbing associated with Eisenmenger's syndrome b) bacterial endocarditis c) atrial myxoma 3) pulmonary disease a) lung cancer - primary & metastatic cancer (35% large cell carcinoma) b) bronchiectasis c) lung abscess, empyema d) mesothelioma e) tuberculosis f) cystic fibrosis g) pulmonary hypertension h) pulmonary arteriovenous shunt - emphysema i) hypertrophic pulmonary osteoarthropathy j) pulmonary fibrosis - Hamman-Rich syndrome; idiopathic alveolar fibrosis - idiopathic pulmomary fibrosis (most common cause of clubbing) 4) gastrointestinal disease a) inflammatory bowel disease 1] ulcerative colitis 2] Crohn's disease b) hepatic cirrhosis c) malabsorption - celiac disease 5) others a) hyperthyroidism b) vascular anomalies of the affected arm C: cyanotic heart disease L: lung cancer, lung abscess, lung fibrosis, lung AV malformation U: ulcerative colitis B: bronchiectasis B: benign mesothelioma I: infective endocarditis N: neurogenic tumors G: gastrointestinal diseases, i.e. cirrhosis, regional enteritis Pathology: 1) hyperplasia of the fibrovascular tissue between the nail matrix & the bony phalynx 2) increased blood supply to the fingers 3) may be a result of humoral vasodilator 4) platelet precursors fail to fragment into platelets in pulmonary circulation 5) platelet precursors become trapped in peripheral vasculature releasing PDGF, VEGF, increased vascularity [4] Clinical manifestations: 1) thickening & widening of the distal end of the digits, fingers & toes 2) increased convexity of the nail fold [8] 3) the angle made by the proximal nail fold & the nail plate (Lovibond's angle) exceeds 180 degrees 4) the tissue between the nail plate & the underlying bone has a spongy quality 5) cyanosis is present with cyanotic heart disease & some forms of pulmonary disease * images [10,11]

Related

Lovibond's angle nail fold (paronychium) nail matrix nail plate

Specific

clubbed fingers clubbed toes

General

sign/symptom nail disease

References

  1. Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 502
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 720
  3. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 183
  4. Spicknall KE et al, Clubbing: an updated on diagosis, differential diagnosis, pathophysiology and clinical relevance J Am Acad Dermatol 2005; 52:1020 PMID: 15928621
  5. Myers KA, Farquhar DR. The rational clinical examination: does this patient have clubbing? JAMA. 2001;286:341-7. PMID: 11466101
  6. Sridhar KS, Lobo CF, Altman RD. Digital clubbing and lung cancer. Chest 1998;114:1535-37. PMID: 9872183
  7. Naeije R. Hepatopulmonary syndrome and portopulmonary hypertension. Swiss Med Wkly. 2003;133:163-9. PMID: 12715285
  8. Clubbing, Wikipedia (accessed 06/26/06) http://en.wikipedia.org/wiki/Clubbing
  9. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018
  10. Schwartz RA, James WD (image) Medscape: Clubbing of the Nails http://emedicine.medscape.com/article/1105946-overview
  11. DermNet NZ (images) Hypertrophic osteoarthropathy and digital clubbing http://www.dermnetnz.org/systemic/clubbing.html