Clubbing of the Nails Clinical Presentation

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Feb 28, 2012
 

History

The development of clubbing usually is gradual enough that many patients are unaware of its presence; however, some patients may report swelling of the distal portion of the digits, which may be bilateral or unilateral or may involve a single digit.

Although clubbing typically is painless, it rarely may present with pain in the fingertips.

Rapid postoperative resolution of clubbing in a few days was described in a patient with aortic and mitral valve replacement due to infective endocarditis.[8]

Hypertrophic osteoarthropathy may occur as an isolated calcaneal periostitis bilaterally.[9]

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Physical

Clubbing is a clinical finding characterized by bulbous fusiform enlargement of the distal portion of a digit (see the image below).

Clubbed fingernail. Clubbed fingernail.

When the profile of the distal digit is viewed, the angle made by the proximal nail fold and nail plate (Lovibond angle) typically is less than or equal to 160°. In clubbing, the angle flattens out and increases as the severity of the clubbing increases. If the angle is greater than 180°, definitive clubbing exists. An angle between 160-180° falls in a gray area and may indicate early stages of clubbing or a pseudoclubbing phenomenon.

Individuals without clubbing display a diamond-shaped window at the base of the nail beds when the dorsum of 2 fingers from the opposite hands are opposed. The distal angle between the 2 opposed nails should be minimal. In individuals with digital clubbing, the diamond window is obliterated and the distal angle between the nails increases with increasing severity of clubbing.

The nail moves more freely in patients with clubbing; therefore, the examiner may note a spongy sensation as the nail is pressed toward the nail plate. The sponginess results from increased fibrovascular tissue between the nail and the phalanx. The skin at the base of the nail may be smooth and shiny.

Obliteration in clubbed fingers of the diamond-shaped window normally produced when the dorsal surfaces of the corresponding finger of each hand are opposed (Schamroth sign) may useful for the identification of clubbing.[10]

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Causes

Clubbing can be idiopathic or secondary to many underlying pathologies in various organ systems.

Causes of idiopathic or primary clubbing include pachydermoperiostosis, familial clubbing, and hypertrophic osteoarthropathy.[11, 12]

Causes of secondary clubbing include the following[13] :

  • Pulmonary disease - Lung cancer,[14] cystic fibrosis, interstitial lung disease,[15] idiopathic pulmonary fibrosis,[16] sarcoidosis,[17] lipoid pneumonia, empyema, pleural mesothelioma, pulmonary artery sarcoma,[18] cryptogenic fibrosing alveolitis, lung hydatid cysts,[19] and pulmonary metastases (see Dermatologic Manifestations of Pulmonary Disease)
  • Cardiac disease - Cyanotic congenital heart disease,[20] other causes of right-to-left shunting, and bacterial endocarditis (see Dermatologic Manifestations of Cardiac Disease)
  • Gastrointestinal disease - Ulcerative colitis, Crohn disease, primary biliary cirrhosis, cirrhosis of the liver, leiomyoma of the esophagus, achalasia, and peptic ulceration of the esophagus (see Dermatologic Manifestations of Gastrointestinal Disease)[21]
  • Skin disease - Pachydermoperiostosis, Bureau-Barrière-Thomas syndrome, Fischer syndrome, palmoplantar keratoderma,[22] and Volavsek syndrome
  • Malignancies - Thyroid cancer, thymus cancer, Hodgkin disease,[23] and disseminated chronic myeloid leukemia (POEMS [polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes] syndrome is a rare paraneoplastic syndrome secondary to a plasma cell dyscrasia in which clubbing may be seen.[24] Other findings including peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasma proliferative disorder, skin changes, sclerotic bone lesions, Castleman disease, thrombocytosis, papilledema, peripheral edema, pleural effusions, ascites, and white nails.)
  • Miscellaneous conditions - Acromegaly, thyroid acropachy, pregnancy, an unusual complication of severe secondary hyperparathyroidism,[25] and hypoxemia possibly related to long-term smoking of cannabis[26]

Hypertrophic osteoarthropathy in adults is often a sign of internal cancer.[27] Other stigmata may also be evident, such as acquired keratoderma taking on a yellow velvety appearance with accentuation of dermatoglyphic lines.

As a paraneoplastic syndrome, it is most commonly associated with non–small-cell lung cancer, although it may occur with metastatic melanoma and other cancers.[28] Hypertrophic pulmonary osteoarthropathy is evident in 1- 5 % of all patients with non–small-cell lung cancer.[29]

Nail changes in 100 chronic renal failure patients undergoing hemodialysis and 100 matched controls were assessed.[30] Nail disorders were more prevalent in the renal failure patients (76%) than in the control group (30%). The half-and-half nail was the most common finding (20%), followed by absent lunula, onycholysis, brittle nail, Beau lines, clubbing, longitudinal ridging, onychomycosis, subungual hyperkeratosis, koilonychias, total leukonychia, splinter hemorrhage, pitting, and pincer nail deformity.

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Gregory M Richards, MD  Clinical Assistant Professor, Department of Human Oncology, University of Wisconsin School of Medicine and Public Health

Gregory M Richards, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Medical Association, American Roentgen Ray Society, American Society of Clinical Oncology, American Society of Therapeutic Radiation Oncology, and Radiological Society of North America

Disclosure: Nothing to disclose.

Supriya Goyal, MD  Consulting Dermatologist

Supriya Goyal, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard K Scher, MD  Adjunct Professor of Dermatology, University of North Carolina; Professor Emeritus of Dermatology, Columbia University

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Dermatological Association, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Warren R Heymann, MD  Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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