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| | __NOTOC__ |
| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = Clubbing | | | Name = Clubbing | |
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| ICD9 = {{ICD9|781.5}} | | | ICD9 = {{ICD9|781.5}} | |
| }} | | }} |
| {{SI}} | | {{Clubbing}} |
| {{CMG}}
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| {{Editor Help}}
| | '''For patient information, click [[Clubbing (patient information)|Clubbing]]''' |
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| == Overview ==
| | {{CMG}}; {{JFS}} |
| In [[medicine]], '''clubbing''', ''finger clubbing'', or ''digital clubbing'' is a deformity of the [[finger]]s and [[Nail (anatomy)|fingernail]]s that is associated with a number of diseases, mostly of the [[heart disease|heart]] and [[lung disease|lungs]]. [[Idiopathic]] clubbing can also occur. [[Hippocrates]] was probably the first to document clubbing as a sign of disease, and the phenomenon is therefore occasionally called '''Hippocratic fingers'''.
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| ==Epidemiology==
| | {{SK}} Digital clubbing; Hippocratic fingers; Hippocratic nails; drumstick fingers; watch glass nails; finger clubbing |
| The exact frequency of clubbing in the population is not known. A 2008 study found clubbing in 1% of all patients admitted to a department of [[internal medicine]]. Of these, 40% turned out to have significant underlying disease of various causes, while 60% had no medical problems on further investigations and remained well over the subsequent year.<ref>{{cite journal |author=Vandemergel X, Renneboog B |title=Prevalence, aetiologies and significance of clubbing in a department of general internal medicine |journal=Eur. J. Intern. Med. |volume=19 |issue=5 |pages=325–9 |year=2008 |month=July |pmid=18549933 |doi=10.1016/j.ejim.2007.05.015}}</ref>
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| ==Pathophysiology== | | ==[[Clubbing overview|Overview]]== |
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| The exact cause for sporadic clubbing is unknown, and there are numerous theories as to its cause. [[Vasodilation]] (distended blood vessels), secretion of [[growth factor]]s (such as [[platelet-derived growth factor]] and [[hepatocyte growth factor]]) from the lungs, and other mechanisms have been proposed. The discovery of disorders in the [[prostaglandin]] metabolism in primary osteo-arthropathy has led to suggestions that overproduction of PGE2 by other tissues may be the causative factor for clubbing.<ref>Uppal S, Diggle CP, Carr IM, et al (June 2008). "Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy". Nat. Genet. 40 (6): 789–93. doi:10.1038/ng.153. PMID 18500342</ref>
| | ==[[Clubbing historical perspective|Historical Perspective]]== |
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| ==Diagnosis== | | ==[[Clubbing classification|Classifications]]== |
| ==Signs and symptoms==
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| Clubbing develops in five steps:<ref name=Myers>{{cite journal | author=Myers KA, Farquhar DR | title=The rational clinical examination: does this patient have clubbing? | journal=JAMA | year=2001 | volume=286 | pages=341–7 | pmid=11466101 | url= | doi=10.1001/jama.286.3.341}}</ref>
| | ==[[Clubbing pathophysiology|Pathophysiology]]== |
| # Fluctuation and softening of the nail bed (increased ballotability)
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| # Loss of the normal <165° angle ("''Lovibond angle''") between the nailbed and the fold (''cuticula'')
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| # Increased convexity of the nail fold
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| # Thickening of the whole [[distal]] (end part of the) finger (resembling a drumstick)
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| # Shiny aspect and [[striation]] of the nail and skin
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| ''Schamroth's test'' or ''Schamroth's window test'' (originally demonstrated by South African cardiologist Dr Leo Schamroth on himself<ref>{{cite journal |author=Schamroth L |title=Personal experience |journal=S. Afr. Med. J. |volume=50 |issue=9 |pages=297–300 |year=1976 |month=February |pmid=1265563}}</ref>) is a popular test for clubbing. When the distal [[phalanges]] (bones nearest the fingertips) of corresponding fingers of opposite hands are directly [[wikt:appose|apposed]] (placed against each other back to back), a small diamond-shaped "window" is normally apparent between the nailbeds. If this window is obliterated, the test is positive and clubbing is present.
| | ==[[Clubbing causes|Causes]]== |
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| When clubbing is encountered in patients, doctors will seek to identify its cause. They usually accomplish this by obtaining a [[anamnesis|medical history]]— particular attention is paid to lung, heart, and gastrointestinal conditions —and conducting a [[clinical examination]], which may disclose associated features relevant to a diagnosis. Additional studies such as a chest x-ray may also be performed.
| | ==[[Clubbing differential diagnosis|Differentiating Clubbing from other Disorders]]== |
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| <gallery>
| | ==[[Clubbing epidemiology and demographics|Epidemiology and Demographics]]== |
| Image:Clubbing.png|Clubbing of the fingernail. The red line shows the outline of a clubbed nail.
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| </gallery>
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| ===Physical Examination=== | | ==[[Clubbing risk factors|Risk Factors]]== |
| ==== Extremities ====
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| [[Image:clubbing.jpg|thumb|left|Clubbing<ref>http://picasaweb.google.com/mcmumbi/USMLEIIImages</ref>]] | |
| <br clear="left"/>
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| ==Disease associations== | | ==[[Clubbing natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| Although many diseases are associated with clubbing (particularly lung diseases), the reports are fairly anecdotal. Prospective studies of patients presenting with clubbing have not yet been performed, and hence there is no conclusive evidence of these associations.
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| ===Isolated clubbing=== | | ==Diagnosis== |
| | | [[Clubbing history and symptoms|History and Symptoms]] | [[Clubbing physical examination|Physical Examination]] | [[Clubbing laboratory findings|Laboratory Findings]] | [[Clubbing electrocardiogram|Electrocardiogram]] | [[Clubbing chest x ray|X Rays]] | [[Clubbing CT|CT]] | [[Clubbing echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Clubbing other diagnostic studies|Other Diagnostic Studies]] |
| Clubbing is associated with:
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| * Lung disease:
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| ** [[Lung cancer]], mainly large-cell (35% of all cases), not seen frequently in small cell lung cancer<ref>Sridhar KS, Lobo CF, Altman RD. Digital clubbing and lung cancer. ''Chest'' 1998;114:1535-37. PMID 9872183</ref>
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| ** [[Interstitial lung disease]]
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| ** [[Tuberculosis]]
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| ** [[Bronchiectasis]]
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| ** Suppurative lung disease: [[lung abscess]], [[empyema]]
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| ** [[Cystic fibrosis]]
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| ** [[Pulmonary hypertension]]
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| ** [[Mesothelioma]]
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| ** It is worth noting that clubbing is ''not'' associated with [[chronic obstructive pulmonary disease]] (COPD). Indeed, the presence of clubbing in a patient with COPD should prompt a search for an underlying (lung) cancer.
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| * Heart disease:
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| ** Any disease featuring chronic [[hypoxia (medical)|hypoxia]]
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| ** Congenital cyanotic heart disease (most common cardiac cause)
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| ** [[Endocarditis|Subacute bacterial endocarditis]]
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| ** [[Atrial myxoma]] (benign tumor)
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| * Gastrointestinal and hepatobiliary:
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| ** [[Malabsorption]]
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| ** [[Crohn's disease]] and [[ulcerative colitis]]
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| ** [[Cirrhosis]], especially in [[primary biliary cirrhosis]]<ref>{{cite journal |author=Epstein O, Dick R, Sherlock S |title=Prospective study of periostitis and finger clubbing in primary biliary cirrhosis and other forms of chronic liver disease |journal=Gut |volume=22 |issue=3 |pages=203-6 |year=1981 |pmid=7227854}}</ref>
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| ** Other [[liver]] diseases (in the "hepatopulmonary syndrome", a complication of [[cirrhosis]])<ref>Naeije R. Hepatopulmonary syndrome and portopulmonary hypertension. ''Swiss Med Wkly.'' 2003;133:163-9. PMID 12715285.</ref>
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| * Others:
| | ==Treatment== |
| ** [[Hyperthyroidism]] (''thyroid acropachy'')<ref>{{GPnotebook|-724565997}}</ref>
| | [[Clubbing medical therapy|Medical Therapy]] |
| ** Familial and racial clubbing and "pseudoclubbing" (people of African descent often have what appears to be clubbing)
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| ** Vascular anomalies of the affected arm such as an [[axillary artery]] [[aneurysm]] (in unilateral clubbing)
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| ===Clubbing associated with other symptoms=== | | ==Case Studies== |
| ===HPOA===
| | [[Clubbing case study one|Case #1]] |
| {{main|Periosteal reaction}}
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| [[Image:Marie-Bamberger2.jpg|thumb|right|[[Bone scan]] of a patient with ''Marie-Bamberger syndrome'']] | |
| A special form of clubbing is '''hypertrophic pulmonary osteo-arthropathy''', known in continental Europe as ''Pierre Marie-Bamberger syndrome''. (In dogs the condition is known as [[hypertrophic osteopathy]].) This is the combination of clubbing and thickening of [[periosteum]] (connective tissue lining of the bones) and [[synovium]] (lining of joints), and is often initially diagnosed as [[arthritis]]. It is commonly associated with lung cancer.
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| ===Primary HOA=== | | ==Related Chapters== |
| Primary hypertrophic osteo-arthropathy is HPOA without signs of pulmonary disease. This form has a hereditary component, although subtle cardiac abnormalties can occasionally be found. It is known in continental Europe as the ''Touraine-Solente-Golé syndrome''. This condition has been linked to mutations in the gene on the fourth chromosome (4q33-q34)coding for the enzyme [[15-hydroxyprostaglandin dehydrogenase]] (HPGD); this leads to decreased breakdown of [[PGE2|prostaglandin E2]] and elevated levels of this substance.<ref name=Uppal>{{cite journal |author=Uppal S, Diggle CP, Carr IM, ''et al'' |title=Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy |journal=Nat. Genet. |volume=40 |issue=6 |pages=789–93 |year=2008 |month=June |pmid=18500342 |doi=10.1038/ng.153}}</ref>
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| ===Secondary HOA===
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| It is usually associated with lung cancer, pulmonary infections, cystic fibrosis, right-to-left cardiac shunts, and less often in Hodgkin lymphoma and cirrhosis. Among patients with lung cancer, HOA is most frequently associated with adenocarcinoma and least frequently with small cell carcinoma <ref name="pmid9872183">{{cite journal |author=Sridhar KS, Lobo CF, Altman RD |title=Digital clubbing and lung cancer |journal=Chest |volume=114 |issue=6 |pages=1535–7 |year=1998 |month=December |pmid=9872183 |doi= |url=}}</ref> Rarely, arterial vascular prosthesis infections may be associated with HOA<ref name="pmid16721260">{{cite journal |author=Alonso-Bartolomé P, Martínez-Taboada VM, Pina T, Blanco R, Rodriguez-Valverde V |title=Hypertrophic osteoarthropathy secondary to vascular prosthesis infection: report of 3 cases and review of the literature |journal=Medicine (Baltimore) |volume=85 |issue=3 |pages=183–91 |year=2006 |month=May |pmid=16721260 |doi=10.1097/01.md.0000224714.27508.8b |url=}}</ref>. Clinical features suggestive of vascular infection-related HOA include clubbing or periosteal new bone formation in a single limb.
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| ==See also==
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| * [[Periosteal reaction]] for more on HPOA and primary HOA | | * [[Periosteal reaction]] for more on HPOA and primary HOA |
| * [[clubbed thumb]] | | * [[Clubbed thumb]] |
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| ===Complete Differential Diagnosis of the Causes of Clubbing===
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| (In alphabetical order)
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| * [[achalasia]]
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| * Arteriovenous malformations
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| * Arterial vascular [[prosthesis]] infections
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| * [[Atrial myxoma]]
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| * Bronchial carcinomas
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| * [[Bronchiectasis]]
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| * [[Celiac Sprue]]
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| * [[Cerebrovascular insult]]
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| * Chronic obstructive [[jaundice]]
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| * [[Cirrhosis]]
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| * Cyanotic [[congenital heart disease]]
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| **[[Tetralogy of Fallot]]
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| **[[Total anomalous venous return]]
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| **[[Transposition of the great vessels]]
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| **[[Tricuspid atresia]]
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| **[[Truncus arteriosus]]
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| * [[Cystic Fibrosis]]
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| * [[Emphysema]]
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| * [[Empyema]]
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| * [[Endocarditis]]
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| * [[Heart failure]]
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| * [[Hepatoma]]
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| * [[Hodgkin's lymphoma]]
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| * [[Interstitial lung disease]]
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| * [[Liver tumor]]s
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| * [[Lung abscess]]
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| * [[Mesothelioma]]
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| * [[Pachydermoperiostosis]]
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| * [[Primary biliray cirrhosis]]
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| * [[Pulmonic stenosis]]
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| * Pulmonary artery [[sarcoma]]
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| * [[Pulmonary fibrosis]]
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| * Pulmonary metastases
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| * Right-to-left [[cardiac shunt]]s
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| * [[sarcoidosis]] of the lungs
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| * [[Silicosis]]
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| * [[Thyrotoxicosis]]
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| * [[Tuberculosis]]
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| * [[Ulcerative colitis]]
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| ===Complete Differential Diagnosis of the Causes of Clubbing===
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| (By organ system)
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| {|style="width:80%; height:100px" border="1"
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| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | Cyanotic congenital heart disease, right-to-left [[shunting]], [[bacterial [[endocarditis]], [[Tetralogy of Fallot]], [[Total anomalous venous return]], [[Transposition of the great vessels]], [[Tricuspid atresia]], [[Truncus arteriosus]]
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| [[ulcerative colitis]], [[Crohn disease]], [[primary biliary cirrhosis]], [[cirrhosis]] of the liver, [[leiomyoma]] of the esophagus, [[achalasia]], and [[peptic ulcer]] of the esophagus
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| [[lung cancer]], [[cystic fibrosis]], [[interstitial lung disease]], [[idiopathic pulmonary fibrosis]], [[ sarcoidosis]],[[lipoid pneumonia]], [[empyema]], [[pleural mesothelioma]], pulmonary artery [[sarcoma]], [[cryptogenic fibrosing alveolitis]],pulmonary metastases
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| No underlying causes
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| |}
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| ==References==
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| {{reflist|2}}
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| {{Symptoms and signs}}
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| {{SIB}}
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| [[de:Trommelschlägelfinger]]
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| [[es:Acropaquia]] | | [[es:Acropaquia]] |
| [[fr:Hypocratisme digital]] | | [[fr:Hypocratisme digital]] |
| [[it:Dita_ippocratiche]]
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| [[ja:ばち指]] | | [[ja:ばち指]] |
| [[no:Trommestikkfingre]]
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| [[pt:Hipocratismo digital]] | | [[pt:Hipocratismo digital]] |
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