Chapter 53: Clubbing

PATIENT STORY

A 31-year-old man with congenital heart disease has had these clubbed fingers since his childhood (Figures 53-1 and 53-2). A close view of the fingers shows a widened club-like distal phalanx. He has learned to live with the limitations from his congenital heart disease and his fingers do not bother him at all.

INTRODUCTION

Clubbing is a physical examination finding first described by Hippocrates in 400 BC. Clubbing can be primary (pachydermoperiostosis or hypertrophic osteoarthropathy) or secondary (pulmonary, cardiac, or GI disease or HIV). Diagnosis is clinical, based on nail fold angles and phalangeal depth ratios. The treatment is to correct the underlying cause, after which clubbing may resolve.

SYNONYMS

Hippocratic nails or fingers, drumstick fingers.

EPIDEMIOLOGY

Prevalence in the general population is unknown:

• One percent of adult patients admitted to a general medicine or service.¹

• Thirty-eight percent and 15% of patients with Crohn disease and ulcerative colitis, respectively.²

• Thirty-three percent and 11% of patients with lung cancer and chronic obstructive pulmonary disease (COPD), respectively.³

• Forty percent of patients admitted to a general medicine service with clubbing had a serious medical condition.¹

ETIOLOGY AND PATHOPHYSIOLOGY

• The etiology of clubbing is poorly understood.

• Increased connective tissue growth and angiogenesis in the nail bed result in the remodeling of the finger into a club shape.

• Cytokine release, specifically megakaryocyte release of platelet-activated growth factor and aggregated platelet release of vascular endothelial growth factor, plays a key role.⁴

RISK FACTORS

• Family history.

• History of a disease associated with clubbing such as bronchogenic carcinoma, lymphoma, tuberculosis, cyanotic heart disease, primary biliary cirrhosis, cirrhosis, inflammatory bowel disease or HIV.⁵

DIAGNOSIS

CLINICAL FEATURES

• History of present illness: Gradual onset of painless enlargement at the ends of the fingers and toes.

  • Family history suggests primary hypertrophic osteoarthropathy/familial clubbing.

  • Social history to identify exposure to asbestos, coal mine dust, and pigeons; tobacco use as risk factor for lung cancer; HIV and tuberculosis risk factors.

• Review of systems: Constitutional, pulmonary, cardiac, GI, and musculoskeletal symptoms for clues to an underlying disease.⁵

PHYSICAL EXAMINATION

• Abnormal nail fold angles⁶ (...