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Digital clubbing in pediatric age groupBy Dr. Deboprasad Das

Criterion for clubbing A finger can be called as clubbed finger when:1. lovibond angle > 180 degrees2. Schamroth sign is positive3. phalangeal depth ratio > 1Lovibond angleThe angle between the nail bed and the nail is known as Lovibond angle. Normally its an acute angleIn clubbing the lovibond angle is >180degrees

Lovibond angle

Schamroth signWhen the distalphalanges(bones nearest the fingertips) of corresponding fingers of opposite hands are directlyopposed(place fingernails of same finger on opposite hands against each other, nail to nail), a small diamond-shaped "window" is normally apparent between the nailbeds. If this window is obliterated, the test is positive and clubbing is present.Dr. Schamroth demonstrated it first in his own fingerSchamroths sign

Phalangeal Depth RatioIn a normal finger the Inter phalangeal Depth (IPD) is more than the Distal phalangeal Depth(DPD)In clubbing DPD/IPD>1DPD:IPD>1

Types of clubbingUnilateral or bilateralPrimary or secondaryAcute or chronicAcute clubbingAcute clubbing develops within 2-3 weeks.Mostly seen in: Suppurative lung disorders(in lung abscess clubbing can be seen in 10-14days) Mesothelioma Bacterial endocarditisChronic clubbingChronic clubbing develops in about 6 months as in cyanotic heart diseases such as Tetralogy of Fallot.In bronchiectasis clubbing may take upto 1year to develop

Primary form of clubbingPrimary form of clubbing is generally idiopathic or hereditary.Pachydermopriostosis contributes to about 85% of primary form of clubbing.

Secondary form of clubbingSecondary form of clubbing is mostly secondary to systemic illness affecting mainly respiratory system, cardiovascular system, hepatobiliary system and gastrointestinal system, and hence is bilateral in general.

Suppurative: Bronchiectasis Lung abscess Empyema Pulmonary TB

Respiratory system diseases associated with clubbingNeoplastic: Bronchial adenoma Mesothelioma Bronchogenic carcinoma(common in adults)Cyanotic congenital heart diseases: Tetralogy of Fallot Transposition of Great Cardiac vessels Ventricular Septal Defects Ebstein anomalyCardiovascular diseasesBacterial endocarditisAtrial myxomasChronic congestive heart failureGastrointestinal diseasesCirrhosisMalabsorption syndromeIntestinal polyposisInflammatory bowel disease(ulcerative colitis and Crohns disease)

Endocrine diseasesMyxoedemaThyrotoxicosis

Differential clubbingIt refers to clubbing with cyanosis limited to either upper or lower limbs.Clubbing with cyanosis limited to lower limb is seen in Patent Ductus Arteriosus with a reversed shuntClubbing with cyanosis limited to upper limb is seen in Transposition of great vessels with PDA with reverse shunt.PseudoclubbingAs the name suggests, it refers to appearance of clubbing without actual presence of it, seen in:Hyperparathyroidism: there is excessive resorption of distal phalangesHansens diseaseLeukemia: bone destruction due to secondary deposits

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