Finger clubbing is also called digital clubbing or Hippocratic fingers. It is the phrase doctors use to describe specific changes in the shape of the fingers and fingernails. People with heart or lung problems sometimes have these changes. They usually develop in advanced disease. Finger clubbing happens in more than 3 out of 10 people with non-small cell lung cancer but only about 4 out of 100 people with small cell lung cancer. You may also get it with mesothelioma.

Clubbing is thought to be caused by fluid collecting in the soft tissues at the ends of the fingers. This is caused by more blood flowing to the area than usual, but it is not fully understood why this happens. It may be due to the tumor producing particular chemicals or hormones, which is called a paraneoplastic syndrome.

Clubbing of the fingers is attributed to the nails becoming round and wide, primarily due to thickening of the nail plate. Clubbing of fingers can develop within a few weeks and are often linked with several disease conditions.

Signs and symptoms of Clubbed Fingers

Clubbed nails causes

Clubbed fingers symptoms

Your finder may club with numerous associated signs on them. The following may be some of these symptoms your may have to look at:

  • The nail becomes soft, which gives it a typically appearance as though the nail is detached from the nail bed and floating.
  • The angle between the cuticle and the nail increases, such that they are in aligned in a straight line.
  • The finger tips become enlarged.
  • The tips become warm and red.
  • The nails form a sharper angle with the cuticle.
  • The nail curves downward so it looks like the round part of an upside-down spoon.

Invariably the condition is associated with symptoms of an underlying disorder affecting the lung, heart or the endocrinal system.

Development of clubbed fingers

  • Clubbing develops first in the thumb and forefinger before it eventually spreads to the other fingers. Obliteration in the angles of the nail beds is the first clinical sign and constant feature of the disease. Common symptoms of clubbing include softening of the nail beds. Instead of being firmly attached, the nails may seem to float.
  • They then form a sharper angle with the cuticle and the fingertips may look like it is swollen and bulging.
  • In addition, curvature of the nails pointing downward similar to that of an upside-down spoon wherein the fingertips appear broader and round than usual often suggests blood work-up for hemochromatosis or anemia.
  • For lower extremities, clubbed fingers and toes are difficult to determine as they normally appear bulbous but is often recognizable in the great toe. In mild cases though, minimal changes of the toe and slight pain are sometimes expressed by patients.

Oftentimes, changes in the color of the nails suggests systemic conditions such as hepatic failure and diabetes for unusually white nails, renal failure for half and half nails, arsenic poisoning for prevalent Mee’s line, dark longitudinal streaks for melanoma and chemical staining while longitudinal striations suggests alopecia areata or hair loss and sometimes psoriasis or vitiligo. Furthermore, brown or black discoloration and striations of the nails may suggest presence of early stage HIV.

Clubbed Fingers Causes

Clubbing is changes in the areas under and around the fingernails that occur with some disorders. The nails also show changes. Clubbing can develop quickly, often within weeks. It also can go away quickly when its cause is treated.

The following are causes of clubbed fingers:

Chronic lung problems

More than three-quarters of clubbing conditions can be related to chronic lung issues. Cardiovascular disorders may be involved in up to 15% of clubbing end up to one-tenth of clubbing may be associated with constantly recurring liver and stomach disorders.

Lung cancer

Lung cancer is the most common cause of clubbing. Clubbing often occurs in heart and lung diseases that reduce the amount of oxygen in the blood. These may include:

  • Heart defects that are present at birth(congenital)
  • Chronic lung infections that occur in people with bronchiectasis, cystic fibrosis or lung abscess.
  • Infection of the lining of the heart chambers and heart valves (infectious endocarditis). This can be caused by bacteria, fungi, or other infectious substances
  • Lung disorders in which the deep lung tissues become swollen and then scarred (interstitial lung disease)
  • Other types of cancer, including liver, gastrointestinal, Hodgkin lymphoma

Heredity

The mechanism underlying clubbed fingers is not definitively known. An increased flow of blood through the capillaries due to a neurocirculatory reflex could cause tissue hypertrophy and hyperplasia of the tissues. It is not clear whether the same mechanism contributes to inherit clubbing.

A study of capillary blood flow in inherited clubbing showed no abnormally increased circulation. However, this could be due to the fact that in cases of inherited clubbing, the clubbing process is usually complete by the time studies are undertaken, whereas in acquired clubbing, the process is ongoing.

Acquired clubbing and osteoarthropathy may have different origins. E ach may occur independently. Clubbing and hypertrophic osteoarthropathy often occur simultaneously with an underlying condition. Clubbed fingers may present before any other symptom of an underlying condition. It could, then, be an initial indicator of a tumor or other serious condition.

Inflammation in the heart lining

Inflammation in the lining of the heart and heart valves caused by bacteria, fungi and other infectious substances can also expose someone of getting the disease. Liver Cirrhosis, celiac disease, diarrheal infections, hyperthyroidism, Hodgkin’s lymphoma can be a causative factor as well. Additionally, medical articles also describe rare skin conditions including pachydermoperiostosis and palmoplantar keratoderma as unusual causes of nail clubbing.

Tetralogy of Fallot

Additionally, Tetralogy of Fallot is the most common cause of clubbing. It is named after Dr. Etienne Fallot, who discovered that a congenital heart defect can be fatal when left untreated. The condition causes cyanosis due to the lack of circulating oxygen which is manifested through pale nail beds contrary to the normal pink toned beds. Although it is rare, it is the common cause of cyanotic heart disease.

Other causes of clubbing:

Clubbing may also be related to a number of other conditions, such as liver disease and celiac disease, dysentery, hyperthyroidism, and some forms of cancer, such as liver and stomach cancer. Graves’ disease and Overactive thyroid gland can also result to clubbed fingers.

A specific cause of clubbing is not known. Generally, clubbing occurs with the onset of lung and heart conditions that reduce oxygen levels found in the blood.

  • Congenital defects of the heart.
  • Chronic pulmonary infections that are caused by bacterial or fungal organisms.
  • Bacteria or fungi which infect the heart lining or the heart valves.
  • Illnesses that occur with the swelling and scarring of the tissues of the lung.

Finger Clubbing Stages

Clubbed nails stages

Clubbed fingers

Finger clubbing occurs in stages. First the base of the nail (nail bed) becomes soft and the skin next to the nail bed becomes shiny. The nails then curve more than normal when looked at from the side and this is called scar mouth’s sign. The ends of the fingers may then get larger and are called drumstick fingers.

In the later stages, extra areas of bone may form on the finger joints, wrists and ankles. This is sometimes mistaken for arthritis and is called hypertrophic pulmonary osteoarthropathy.

  1. Hypertrophic osteoarthropathy

This is an advanced stage of clubbed fingers where there is painful periosteal proliferation of long bones such as the radius, ulna, or tibia. The periostitis is often associated with mild fever and arthralgia or joint effusion. Peripheral neurovascular disease with cyanosis, excessive sweating (hyperhidrosis), paresthesias, and muscular weakness can also occur.

  1. Pachydermoperiostosis

This is a syndrome that combines hyper-trophic osteoarthropathy and acromegalic features. Patients with this disorder have cylindrical thickening of the limbs due to periostosis and skin changes. The skin changes include marked thickening and oiliness of the skin of the hands, forearms, and legs; accentuation of facial folds; hyperhidrosis of the hands and feet; and reduplication and furrowing of skin over the scalp.

Grades of clubbed fingers

There are five different grades of digital clubbing, some stages have visible changes while others have moderate to drastic changes.

1st stage

The first stage has zero signs of nail bed altercations. However, in this stage the nail bed starts to soften and slowly fluctuates.

2nd stage

The second stage is mild clubbing. In this stage, there is absence of the normal Lovibond angle but it can only be appreciated upon closer look.

3rd stage

The third stage is the moderate clubbing phase where the convex between the folds of the nails are dramatically increased and fingertip malformation is less palpable.

4th stage

Meanwhile, the fourth stage is the phase where digital clubbing is appreciated even at quick glance. During this stage, the tips of the fingers are slowly beginning to show a curve on each side and the nails begins to widen resembling like that of a chicken leg.

5th stage

Lastly, the fifth stage is the Hypertrophic Osteoarthropathy where on top of an apparent clubbed fingers, extremities have also increased in size. This resembles so much like that of a “bird claw” but is wider in diameter. The angles of the nail beds are greater than usual. In addition, patients would also experience angle and joint swelling.

Consequently, these stages have two types: Primary and Secondary. The former is genetic and is often credited to an autoimmune disorder while the latter is sometimes an underlying symptom of a malignant infection.

Clubbed Fingers Pictures

Clubbing is a physical sign characterized by bulbous enlargement of the ends of one or more fingers or toes. Proliferation and edema of connective tissue result in loss of the normal angle between the skin and nail plate and excessive sponginess of the nail base.

As clubbing progresses, the angle between the nail and the nail base becomes obliterated. Normally, the angle is less than or equal to 160°. With increasing convexity of the nail, the angle becomes greater than 180°. In early clubbing, the nail may feel springy instead of firm when palpated and the skin at the base of the nail may become smooth and shiny.

In individuals without clubbing, if two opposing fingers are placed together, a diamond-shaped window will appear. In clubbing, this window is obliterated and the distal angle formed by the two nails becomes wider. To learn more, have a look at the pictures provide in this post.

Nail Clubbing

Nail clubbing causes

Nail clubbing

Nail Clubbing is the change in angle between the nails and the nail base. People who manifested the disease have upper and lower extremities that are deformed with fingertips that are wider and rounder than usual. It is eventually larger than 180 degrees and is sometimes characterized by softening of the nail beds with flattening of the nails and sometimes enlargement of the fingertips.

Causes of Nail Clubbing

  • Normally, the nails are transparent, smooth, well-rounded and convex with a nail bed angle of about 160 degrees. Clubbed fingers are often an underlying symptom of a congenital cardiovascular disease or a heart ailment.
  • Etiology of this rare condition remains unclear but medical researchers believe that it is prevalent with race and genetic predisposition. Also, it is often associated with undiagnosed pulmonary, cardiovascular, neoplastic infections, as well as hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases.
  • It may also occur as an idiopathic form that is most common in males with inherited autosomal and recessive X-linked trait; this is common in some families with PDP (pachydermoperiostosis). Furthermore, lung cancer or heart defects are the common cause of clubbing as it often occurs in the heart and the lungs where hypoxia occurs (reduced amount of oxygen in the blood).
  • Other common causes of clubbing are Pulmonary Fibrosis, a condition that presents stiffening and scarring of the lung. Bronchiectasis can also be attributed to the cause of the disease as it is an illness where bronchial tubes are permanently damaged and widened and when this happens, less oxygenation of the blood occurs contributing to clubbing of the nails.

Clubbed Fingers Treatment

Only a few weeks may be needed for the onset of clubbing to occur. But after the underlying condition is treated, clubbing will resolve. There is no direct treatment for clubbing itself. Its cause can be treated, and it is usually reversible when the associated condition is treated successfully.

Laboratory investigations

These will depend on the underlying conditions suggested by the overall clinical picture.

Imaging

This is not usually required to diagnose clubbing but plain radiographs of the digits may help to elucidate the cause. Osteolysis is often seen in patients with congenital cyanotic heart disease, whilst bone hypertrophy suggests a pulmonary condition.

Other modalities sometimes employed in clinical and research settings include technetium-99m scanning to assess bone loss, thermography and positron emission tomography (PET) scanning.
CT and MRI scanning of other areas may be required to assist in diagnosing the underlying primary cause.

Prognosis

Clubbing is potentially reversible if the underlying condition is treated early enough but the changes may be irreversible once collagen deposition has set in.

Treatment

The treatment of clubbed fingers primarily focuses on treating the underlying condition. Cancers can be treated with radiation or chemotherapy, while congenital cardiac disorders are treated with surgery. Though clubbing of fingers, itself is not a health concern, there are certain treatment therapies that might be beneficial for management of finger clubbing by treating the underlying cause,

  • Oxygen therapy, comprising on inhaling hyperbaric oxygen for about an hour each day is considered useful to deal with the condition.
  • Avoiding aerosol sprays like deodorants can help in the treatment of lung inflammation caused by exposure to toxins. Using a mask while working can help reduce occupational hazards like asbestosis.
  • Homeopathic drugs like Drosera and Antim Tart are useful in dealing with lung fibrosis. These drugs should be taken only after consultation with a trained homeopathic doctor.
  • Simple deep breathing exercises are considered to be beneficial in improving lung capacity and thereby deal with low oxygen concentration. Yoga therapies like Pranayama and Anulom-Villom are very useful.
  • A healthy diet rich in fresh fruits and green leafy vegetables help boost the hemoglobin levels, which in turn can improve blood oxygen concentration.

Nail Clubbing Treatment

Doctors determine the condition by asking the patients to complete a test called “Schamroth’s Window Test” or also known as “Schamroth’s Test”. The procedure was formulated by a South African doctor Leo Schamroth. It is so popular that it became the definitive test for clubbing of fingers.

Normally, a small diamond shaped window is visible between the nail bed and the nail folds. However, if it looks obliterated or blotted out, this may confirm existence of the disease. In addition, the nail beds also become soft and spongy, the distal part of the fingers are thickened, reduced Lovibond angle is observed and increased convex in the nail folds are also apparent in patients who tested positive.

Diagnostic studies for clubbed fingers are usually laboratory blood work-ups that confirm the underlying conditions but not the disease itself.

  • Imaging studies can also be suggested by physicians to diagnose the presence of such conditions. Firstly, X-ray is used to check evident presence of bone dissolution and bone deformation.
  • Secondly, Technetium Tc 99m Skeletal Imaging can also be recommended as it helps in providing good quality views in determining the extent of bone changes in clubbed digits, this also shows increased levels of blood flow and softening of surrounding tissues.
  • Thirdly, Thermography is another imaging test used to monitor increased temperature in the distal digits of patients testing positive for clubbing as this suggests vasodilation, however, not all clubbing have positive results.
  • Fourthly, Positron emission tomography is used to study glucose metabolism of clubbed digits as increased signals indicates higher glucose metabolism which is often demonstrated in distal parts of the clubbed fingers. These signs aren’t apparent in normal fingers; however, increased signal levels support the study that clubbing is attributed to platelet derived growth factor which increases metabolism.
  • Lastly, Computed Tomography (CT scan) or Magnetic Resonance Imaging (MRI) aids in evaluating the primary causative factor of clubbing. When high frequency ultrasound imaging is used, Primary Hypertrophic Osteoarthropathy is easily presented in the films showing the long bones surrounded by echogenic tissues; this presentation reflects edematous and inflamed tissues which is a confirmative sign of the condition.

Can Nail Clubbing be Reversed?

Nail clubbing causes

Nail clubbing treatment

Although clubbing is irreversible, early detection and treatment can potentially decrease the deformity or even reverse it if treated abruptly the moment it is diagnosed. However, reversal is unlikely the moment depositions of collagen are increased. Consequently, palliative treatment or symptomatic treatment is available.

In addition, there are also known natural remedies for clubbed fingers. Some of the conservative treatments are:

  • A mixture of 3 tablespoons of olive oil and one tablespoon lemon juice in a small bowl wherein clubbed nails are soaked in the mixture for 10 minutes is known to straighten clubbed nails
  • Soaking clubbed nails in a mixture of tomato juice, lemon juice as well as olive oil in a small bowl
  • Application of warm olive oil can also treat the condition
  • Sliced lemons rubbed over the nails in a 5 minute period also promotes natural nail growth
  • Consumption of foods rich in gelatin such as jellies can also be a cure as well
  • Avoidance of eating Vitamin E rich foods such as jojoba oil, wheat germ oil, almond oil and the like
  • Drops of Tea tree oil on the nail beds as well as use of essential oils
  • Salt water treatment for 5 minutes on the nail beds
  • Consumption of green leafy vegetables on a regular basis
  • No cutting of cuticles
  • Overall, nail clubbing can be prevented by consistent hand hygiene and practicing a healthy and well-balanced lifestyle

More references

  1. What is finger clubbing:
  2. Clubbing of the fingers or toes:
  3. Clubbed fingers:
  4. Causes of finger clubbing:
  5. Symptoms of the finger clubbing:
  6. Clubbing of nails:
  7. Clubbing:
  8. Nail clubbing:
  9. Causes of nail clubbing: