Digital clubbing in pediatric age group By Dr. Deboprasad Das

Criterion for clubbing A finger can be called as clubbed finger when: 1. lovibond angle > 180 degrees 2. Schamroth sign is positive 3. phalangeal depth ratio > 1

Lovibond angle The angle between the nail bed and the nail is known as Lovibond angle. Normally its an acute angle In clubbing the lovibond angle is >180degrees

Lovibond angle

Schamroth sign When the distal phalanges (bones nearest the fingertips) of corresponding fingers of opposite hands are directly opposed (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 finger

Schamroth’s sign

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

DPD:IPD>1

Types of clubbing Unilateral or bilateral Primary or secondary Acute or chronic

Acute clubbing Acute clubbing develops within 2-3 weeks. Mostly seen in: Suppurative lung disorders(in lung abscess clubbing can be seen in 10-14days) Mesothelioma Bacterial endocarditis

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

Secondary form of clubbing Secondary 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.

Respiratory system diseases associated with clubbing Neoplastic: Bronchial adenoma Mesothelioma Bronchogenic carcinoma(common in adults) Suppurative: Bronchiectasis Lung abscess Empyema Pulmonary TB

Cardiovascular diseases Cyanotic congenital heart diseases: Tetralogy of Fallot Transposition of Great Cardiac vessels Ventricular Septal Defects Ebstein anomaly Bacterial endocarditis Atrial myxomas Chronic congestive heart failure

Gastrointestinal diseases Cirrhosis Malabsorption syndrome Intestinal polyposis Inflammatory bowel disease(ulcerative colitis and Crohn’s disease)

Endocrine diseases Myxoedema Thyrotoxicosis

Differential clubbing It 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 shunt Clubbing with cyanosis limited to upper limb is seen in Transposition of great vessels with PDA with reverse shunt.

Pseudoclubbing As the name suggests, it refers to appearance of clubbing without actual presence of it, seen in: Hyperparathyroidism: there is excessive resorption of distal phalanges Hansen’s disease Leukemia: bone destruction due to secondary deposits

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