1. Digital clubbing in pediatric age group
By Dr. Deboprasad Das

7. 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

8. 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

9. Lovibond angle

10. 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

11. Schamroth’s sign

12. 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

13. DPD:IPD>1

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

17. 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

18. 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

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

23. 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.

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

25. 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

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

27. Endocrine diseases
Myxoedema
Thyrotoxicosis

30. 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.

31. 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

33. Thank you