Clubbing
A nonspecific sign of pulmonary and cyanotic cardiovascular disorders, clubbing is the painless, usually bilateral increase in soft tissue around the terminal phalanges of the fingers or toes. (See Rare causes of clubbing, page 148.) It doesn't involve changes in the underlying bone. With early clubbing, the normal 160-degree angle between the nail and the nail base approximates 180 degrees. As clubbing progresses, this angle widens and the base of the nail becomes visibly swollen. With late clubbing, the angle where the nail meets the now-convex nail base extends more than halfway up the nail.
History and physical examination
You'll probably detect clubbing while evaluating other signs of known pulmonary or cardiovascular disease. Therefore, review the patient's current plan of treatment because clubbing may resolve with correction of the underlying disorder. Also, evaluate the extent of clubbing in the fingers and toes. (See Checking for clubbed fingers.)
Medical causes
Bronchiectasis.
Clubbing commonly occurs in the late stage of bronchiectasis. Another classic sign is a cough that produces copious, foul-smelling, and mucopurulent sputum. Hemoptysis and coarse crackles over the affected area, heard during inspiration, are also characteristic. The patient may complain of weight loss, fatigue, weakness, and exertional dyspnea. He may also have rhonchi, fever, malaise, and halitosis.
Bronchitis.
With chronic bronchitis, clubbing may occur as a late sign and is unrelated to the severity of the disease. The patient has a chronic productive cough and may display barrel chest, dyspnea, wheezing, increased use of accessory muscles, cyanosis, tachypnea, crackles, scattered rhonchi, and prolonged expiration.
Emphysema.
Clubbing occurs late in emphysema. The patient may have anorexia, malaise, dyspnea, tachypnea, diminished breath sounds, peripheral cyanosis, and pursed-lip breathing. He may also display accessory muscle use, barrel chest, and a productive cough.
Endocarditis.
With subacute infective endocarditis, clubbing may be accompanied by a fever, anorexia, pallor, weakness, night sweats, fatigue, tachycardia, and weight loss. The patient may also develop arthralgia, petechiae, Osler's nodes, splinter hemorrhages, Janeway lesions, splenomegaly, and Roth's spots. Cardiac murmurs are usually present.
Heart failure.
Clubbing occurs as a late sign in heart failure along with wheezing, dyspnea, and fatigue. Other findings include jugular vein distention, hepatomegaly, tachypnea, palpitations, dependent edema, unexplained weight gain, nausea, anorexia, chest tightness, a slowed mental response, hypotension, diaphoresis, narrow pulse pressure, pallor, oliguria, a gallop rhythm (a third heart sound),and crackles on inspiration.
Interstitial fibrosis.
Clubbing usually occurs in the patient with advanced interstitial fibrosis. Typically, he also develops intermittent chest pain, dyspnea, crackles, fatigue, weight loss, and possible cyanosis.
Lung abscess.
Initially, lung abscess produces clubbing, which may reverse with resolution of the abscess. It can also cause pleuritic chest pain; dyspnea; crackles; a productive cough with a lot of purulent, foul-smelling, usually bloody sputum; and halitosis. The patient may also experience weakness, fatigue, anorexia, a headache, malaise, weight loss, and a fever with chills. You may hear decreased breath sounds.
Lung and pleural cancer.
Clubbing occurs commonly in lung and pleural cancers. Associated findings include hemoptysis, dyspnea, wheezing, chest pain, weight loss, anorexia, fatigue, and a fever.
Special considerations
Don't mistake curved nails — a normal variation — for clubbing. Simply remember that the angle between the nail and its base remains normal in curved nails, but not in clubbed nails.
Pediatric pointers
In children, clubbing usually occurs in those with cyanotic congenital heart disease or cystic fibrosis. Surgical correction of heart defects may reverse clubbing.
Geriatric pointers
Arthritic deformities of the fingers or toes may disguise the presence of clubbing.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Finger symptoms
Read excerpts from these other book chapters related to Finger symptoms:
Medical Books Excerpts
- Clubbing
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Clubbing
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Clubbing
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Clubbing
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Clubbing
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Finger symptoms
» Next page: Clubbing (A Pocket Manual of Differential Diagnosis)
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