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| ICD9 = {{ICD9|781.5}} | | | ICD9 = {{ICD9|781.5}} | |
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| {{SI}} | | {{Clubbing}} |
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| | '''For patient information, click [[Clubbing (patient information)|Clubbing]]''' |
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| {{CMG}}; {{JFS}} | | {{CMG}}; {{JFS}} |
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| {{SK}} Digital clubbing; Hippocratic fingers; Drumstick fingers; Watch glass nails | | {{SK}} Digital clubbing; Hippocratic fingers; Hippocratic nails; drumstick fingers; watch glass nails; finger clubbing |
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| == Overview ==
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| In [[medicine]], '''clubbing''', ''finger clubbing'', or ''digital clubbing'' is a deformity of the [[finger]]s and [[Nail (anatomy)|fingernail]]s that is associated with a number of diseases, mostly of the [[heart disease|heart]] and [[lung disease|lungs]]. [[Idiopathic]] clubbing can also occur.
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| ==Historical Perspective==
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| [[Hippocrates]] was probably the first to document clubbing as a sign of disease, and the phenomenon is therefore occasionally called '''Hippocratic fingers'''.
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| ==Pathophysiology== | | ==[[Clubbing overview|Overview]]== |
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| The exact cause for sporadic clubbing is unknown, and there are numerous theories as to its cause. [[Vasodilation]] (distended blood vessels), secretion of [[growth factor]]s (such as [[platelet-derived growth factor]] and [[hepatocyte growth factor]]) from the lungs, and other mechanisms have been proposed. The discovery of disorders in the [[prostaglandin]] metabolism in primary osteo-arthropathy has led to suggestions that overproduction of [[PGE2]] by other tissues may be the causative factor for clubbing.<ref>Uppal S, Diggle CP, Carr IM, et al (June 2008). "Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy". Nat. Genet. 40 (6): 789–93. doi:10.1038/ng.153. PMID 18500342</ref>
| | ==[[Clubbing historical perspective|Historical Perspective]]== |
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| ===Associated Conditions=== | | ==[[Clubbing classification|Classifications]]== |
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| Although many diseases are associated with clubbing such as oxygen deprivation and lung, heart, or liver disease, the reports are fairly anecdotal. Prospective studies of patients presenting with clubbing have not yet been performed, and hence there is no conclusive evidence of these associations.
| | ==[[Clubbing pathophysiology|Pathophysiology]]== |
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| * Lung disease:
| | ==[[Clubbing causes|Causes]]== |
| ** [[Lung cancer]], mainly large-cell (35% of all cases), not seen frequently in small cell lung cancer<ref>Sridhar KS, Lobo CF, Altman RD. Digital clubbing and lung cancer. ''Chest'' 1998;114:1535-37. PMID 9872183</ref>
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| ** [[Interstitial lung disease]]
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| ** [[Tuberculosis]]
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| ** [[Bronchiectasis]]
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| ** Suppurative lung disease: [[lung abscess]], [[empyema]]
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| ** [[Cystic fibrosis]]
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| ** [[Pulmonary hypertension]]
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| ** [[Mesothelioma]]
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| ** It is worth noting that clubbing is ''not'' associated with [[chronic obstructive pulmonary disease]] (COPD). Indeed, the presence of clubbing in a patient with COPD should prompt a search for an underlying (lung) cancer.
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| * Heart disease:
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| ** Any disease featuring chronic [[hypoxia (medical)|hypoxia]]
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| ** [[Congenital heart disease cyanotic|Congenital cyanotic heart disease]] (most common cardiac cause)
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| ** [[Endocarditis|Subacute bacterial endocarditis]]
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| ** [[Atrial myxoma]] (benign tumor)
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| * Gastrointestinal and hepatobiliary:
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| ** [[Malabsorption]]
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| ** [[Crohn's disease]] and [[ulcerative colitis]]
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| ** [[Cirrhosis]], especially in [[primary biliary cirrhosis]]<ref>{{cite journal |author=Epstein O, Dick R, Sherlock S |title=Prospective study of periostitis and finger clubbing in primary biliary cirrhosis and other forms of chronic liver disease |journal=Gut |volume=22 |issue=3 |pages=203-6 |year=1981 |pmid=7227854}}</ref>
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| ** Other [[liver]] diseases (in the "hepatopulmonary syndrome", a complication of [[cirrhosis]])<ref>Naeije R. Hepatopulmonary syndrome and portopulmonary hypertension. ''Swiss Med Wkly.'' 2003;133:163-9. PMID 12715285.</ref>
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| * Others:
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| ** [[Hyperthyroidism]] (''thyroid acropachy'')<ref>{{GPnotebook|-724565997}}</ref>
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| ** Familial and racial clubbing and "pseudoclubbing" (people of African descent often have what appears to be clubbing)
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| ** Vascular anomalies of the affected arm such as an [[axillary artery]] [[aneurysm]] (in unilateral clubbing)
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| *HPOA
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| **A special form of clubbing is [[hypertrophic pulmonary osteo-arthropathy]], known in continental Europe as [[Pierre Marie-Bamberger syndrome]]. (In dogs the condition is known as hypertrophic osteopathy.) This is the combination of clubbing and thickening of periosteum (connective tissue lining of the bones) and synovium (lining of joints), and is often initially diagnosed as arthritis. It is commonly associated with lung cancer.
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| *Primary HOA
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| **Primary hypertrophic osteo-arthropathy is HPOA without signs of pulmonary disease. This form has a hereditary component, although subtle cardiac abnormalties can occasionally be found. It is known in continental Europe as the ''Touraine-Solente-Golé syndrome''. This condition has been linked to mutations in the gene on the fourth chromosome (4q33-q34)coding for the enzyme [[15-hydroxyprostaglandin dehydrogenase]] (HPGD); this leads to decreased breakdown of [[PGE2|prostaglandin E2]] and elevated levels of this substance.<ref name=Uppal>{{cite journal |author=Uppal S, Diggle CP, Carr IM, ''et al'' |title=Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy |journal=Nat. Genet. |volume=40 |issue=6 |pages=789–93 |year=2008 |month=June |pmid=18500342 |doi=10.1038/ng.153}}</ref>
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| *Secondary HOA
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| **It is usually associated with [[lung cancer]], pulmonary infections, [[cystic fibrosis]], [[right-to-left cardiac shunts]], and less often in [[Hodgkin's lymphoma]] and [[cirrhosis]]. Among patients with lung cancer, HOA is most frequently associated with [[adenocarcinoma]] and least frequently with [[small cell carcinoma]] <ref name="pmid9872183">{{cite journal |author=Sridhar KS, Lobo CF, Altman RD |title=Digital clubbing and lung cancer |journal=Chest |volume=114 |issue=6 |pages=1535–7 |year=1998 |month=December |pmid=9872183 |doi= |url=}}</ref> Rarely, [[arterial vascular prosthesis infections]] may be associated with HOA<ref name="pmid16721260">{{cite journal |author=Alonso-Bartolomé P, Martínez-Taboada VM, Pina T, Blanco R, Rodriguez-Valverde V |title=Hypertrophic osteoarthropathy secondary to vascular prosthesis infection: report of 3 cases and review of the literature |journal=Medicine (Baltimore) |volume=85 |issue=3 |pages=183–91 |year=2006 |month=May |pmid=16721260 |doi=10.1097/01.md.0000224714.27508.8b |url=}}</ref>. Clinical features suggestive of vascular infection-related HOA include clubbing or periosteal new bone formation in a single limb.
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| ===Gross Pathology=== | | ==[[Clubbing differential diagnosis|Differentiating Clubbing from other Disorders]]== |
| [[Image:clubbing.jpg|thumb|left|Clubbing<ref>http://picasaweb.google.com/mcmumbi/USMLEIIImages</ref>]] | |
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| ==Causes== | | ==[[Clubbing epidemiology and demographics|Epidemiology and Demographics]]== |
| === Causes by Organ System ===
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| {|style="width:80%; height:100px" border="1"
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| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Congenital heart disease cyanotic|Cyanotic congenital heart disease]], [[Right-to-left shunt|Right-to-left shunting]], [[Bacterial endocarditis]], [[Tetralogy of fallot]], [[Total anomalous pulmonary venous connection]], [[Transposition of the great vessels]], [[Tricuspid atresia]], [[Truncus arteriosus]], [[Arteriovenous malformation]]s , [[Arterial vascular prosthesis infections]], [[Atrial myxoma]], [[Pulmonic stenosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| [[Cannabis]], [[Lipoid pneumonia]],
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| [[Cannabis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| [[Nasopharyngeal carcinoma]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| [[Thyroid cancer]], [[Thyrotoxicosis]]
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| | ==[[Clubbing risk factors|Risk Factors]]== |
| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| [[Mesothelioma]], [[Silicosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| [[Ulcerative colitis]], [[Crohn disease]], [[Primary biliary cirrhosis]], [[Cirrhosis]] of the liver, [[Leiomyoma]] of the esophagus, [[Achalasia]], and [[Peptic ulcer]] of the esophagus, [[Celiac sprue]], [[Hepatoma]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| [[Cystic fibrosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| [[Myelofibrosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| [[Cannabis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| [[Tuberculosis]], [[Empyema]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| [[Cerebrovascular insult]]
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| [[Thyroid cancer]], [[Thymus cancer]], [[Hodgkin's disease]], [[POEMS syndrome]], [[Metastatic]] [[melanoma]], [[Mesothelioma]], [[Nasopharyngeal carcinoma]], [[Myelofibrosis]], [[Atrial myxoma]],
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| |- | |
| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| [[Lung cancer]], [[Cystic fibrosis]], [[Interstitial lung disease]], [[Idiopathic pulmonary fibrosis]], [[Sarcoidosis]],[[Lipoid pneumonia]], [[Empyema]], [[Pleural mesothelioma]], [[Pulmonary artery sarcoma]], [[Cryptogenic fibrosing alveolitis]], [[Pulmonary metastasis]], [[Bronchiectasis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| [[Sarcoidosis]]
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| |-
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| |}
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| ===Causes in Alphabetical Order=== | | ==[[Clubbing natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| * [[Achalasia]]
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| * [[Arteriovenous malformation]]s
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| * [[Arterial vascular prosthesis infections]] <ref name="pmid16721260">{{cite journal |author=Alonso-Bartolomé P, Martínez-Taboada VM, Pina T, Blanco R, Rodriguez-Valverde V |title=Hypertrophic osteoarthropathy secondary to vascular prosthesis infection: report of 3 cases and review of the literature |journal=Medicine (Baltimore) |volume=85 |issue=3 |pages=183–91 |year=2006 |month=May |pmid=16721260 |doi=10.1097/01.md.0000224714.27508.8b |url=}}</ref>
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| * [[Atrial myxoma]]
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| * [[Bronchial carcinoma]]<ref>Sridhar KS, Lobo CF, Altman RD. Digital clubbing and lung cancer. ''Chest'' 1998;114:1535-37. PMID 9872183</ref>
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| * [[Bronchiectasis]]
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| * [[Cannabis]] <ref name="pmid18238953">{{cite journal |author=Schuller A, Cottin V, Hot A, Cordier JF |title=Finger clubbing and altered carbon monoxide transfer capacity in cannabis smokers |journal=Eur. Respir. J. |volume=31 |issue=2 |pages=473–4 |year=2008 |month=February |pmid=18238953 |doi=10.1183/09031936.00150907 |url=}}</ref>
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| * [[Celiac Sprue]]<ref name="pmid16238129">{{cite journal |author=Gajewska J, Ambroszkiewicz J, Hozyasz KK |title=[The impairement of bone formation and resorption in 25-year-old man with neglected celiac disease] |language=Polish |journal=Wiad. Lek. |volume=58 |issue=5-6 |pages=338–41 |year=2005 |pmid=16238129 |doi= |url=}}</ref>
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| * [[Cerebrovascular insult]]
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| * Chronic obstructive [[jaundice]]
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| * [[Cirrhosis]]
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| * [[Cyanotic congenital heart disease]]<ref name="pmid3909407">{{cite journal |author=Pineda CJ, Guerra J, Weisman MH, Resnick D, Martinez-Lavin M |title=The skeletal manifestations of clubbing: a study in patients with cyanotic congenital heart disease and hypertrophic osteoarthropathy |journal=Semin. Arthritis Rheum. |volume=14 |issue=4 |pages=263–73 |year=1985 |month=May |pmid=3909407 |doi= |url=}}</ref>
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| **[[Tetralogy of Fallot]]
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| **[[Total anomalous venous connection]]
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| **[[Transposition of the great vessels]]
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| **[[Tricuspid atresia]]
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| **[[Truncus arteriosus]]
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| * [[Cystic Fibrosis]]<ref name="pmid16504602">{{cite journal |author=Van Ginderdeuren F, Van Cauwelaert K, Malfroot A |title=Influence of digital clubbing on oxygen saturation measurements by pulse-oximetry in cystic fibrosis patients |journal=J. Cyst. Fibros. |volume=5 |issue=2 |pages=125–8 |year=2006 |month=May |pmid=16504602 |doi=10.1016/j.jcf.2006.01.007 |url=}}</ref>
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| * [[Endocarditis]]<ref name="pmid18843516">{{cite journal |author=Ozdemir B, Sentürk T, Kaderli AA, ''et al.'' |title=Postoperative regression of clubbing at an unexpected rate in a patient with aortic and mitral valve replacement due to infective endocarditis |journal=Ir J Med Sci |volume= |issue= |pages= |year=2008 |month=October |pmid=18843516 |doi=10.1007/s11845-008-0231-2 |url=}}</ref>
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| * [[Empyema]]
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| * [[Hepatoma]]
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| * [[Hodgkin's lymphoma]]<ref name="pmid5553121">{{cite journal |author=Mullins GM, Lenhard RE |title=Digital clubbing in Hodgkin's disease |journal=Johns Hopkins Med J |volume=128 |issue=3 |pages=153–7 |year=1971 |month=March |pmid=5553121 |doi= |url=}}</ref>
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| * [[Interstitial lung disease]]
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| * [[Liver tumor]]s
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| * [[Lung abscess]]<ref name="pmid17273583">{{cite journal |author=Moreira Jda S, Camargo Jde J, Felicetti JC, Goldenfun PR, Moreira AL, Porto Nda S |title=Lung abscess: analysis of 252 consecutive cases diagnosed between 1968 and 2004 |journal=J Bras Pneumol |volume=32 |issue=2 |pages=136–43 |year=2006 |pmid=17273583 |doi= |url=}}</ref>
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| * [[Metastatic melanoma]]<ref name="pmid16314744">{{cite journal |author=Thompson MA, Warner NB, Hwu WJ |title=Hypertrophic osteoarthropathy associated with metastatic melanoma |journal=Melanoma Res. |volume=15 |issue=6 |pages=559–61 |year=2005 |month=December |pmid=16314744 |doi= |url=}}</ref>
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| * [[Mesothelioma]]<ref name="pmid9659538">{{cite journal |author=McGavin C, Hughes P |title=Finger clubbing in malignant mesothelioma and benign asbestos pleural disease |journal=Respir Med |volume=92 |issue=4 |pages=691–2 |year=1998 |month=April |pmid=9659538 |doi= |url=}}</ref>
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| * [[Myelofibrosis]]<ref name="pmid18038138">{{cite journal |author=Saghafi M, Azarian A, Nohesara N |title=Primary hypertrophic osteoarthropathy with myelofibrosis |journal=Rheumatol. Int. |volume=28 |issue=6 |pages=597–600 |year=2008 |month=April |pmid=18038138 |doi=10.1007/s00296-007-0477-4 |url=}}</ref>
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| * [[Nasopharyngeal carcinoma]]<ref name="pmid19402293">{{cite journal |author=Ali N, Abbasi AN, Karsan F, Hashmi R, Badar QA, Sheikh AJ |title=A case of finger clubbing associated with nasopharyngeal carcinoma in a young girl, and review of pathophysiology |journal=J Pak Med Assoc |volume=59 |issue=4 |pages=253–4 |year=2009 |month=April |pmid=19402293 |doi= |url=}}</ref>
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| * [[Pachydermoperiostosis]]
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| * [[POEMS syndrome]] ([[polyneuropathy]], [[organomegaly]], [[endocrinopathy]], [[monoclonal gammopathy]], and [[skin changes]]): a rare paraneoplastic syndrome secondary to a plasma cell dyscrasia in which clubbing may be seen. Other findings including peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasma proliferative disorder, skin changes, sclerotic bone lesions, Castleman disease, thrombocytosis, papilledema, peripheral edema, pleural effusions, ascites, and white nails.
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| * [[Primary biliary cirrhosis]]<ref name="pmid2295472">{{cite journal |author=Stoller JK, Moodie D, Schiavone WA, ''et al.'' |title=Reduction of intrapulmonary shunt and resolution of digital clubbing associated with primary biliary cirrhosis after liver transplantation |journal=Hepatology |volume=11 |issue=1 |pages=54–8 |year=1990 |month=January |pmid=2295472 |doi= |url=}}</ref>
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| * [[Pulmonic stenosis]]
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| * [[Pulmonary artery sarcoma]]<ref name="pmid8769527">{{cite journal |author=Loredo JS, Fedullo PF, Piovella F, Moser KM |title=Digital clubbing associated with pulmonary artery sarcoma |journal=Chest |volume=109 |issue=6 |pages=1651–3 |year=1996 |month=June |pmid=8769527 |doi= |url=}}</ref>
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| * [[Pulmonary fibrosis]]
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| * [[Pulmonary metastases]]
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| * [[Right-to-left cardiac shunt]]s
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| * [[Sarcoidosis]] of the lungs <ref name="pmid">{{cite journal |author=West SG, Gilbreath RE, Lawless OJ |title=Painful clubbing and sarcoidosis |journal=JAMA |volume=246 |issue=12 |pages=1338–9 |year=1981 |month=September |pmid= |doi= |url=}}</ref>
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| * [[Silicosis]]<ref name="pmid3340919">{{cite journal |author=Ehrlich RI, Gerston KF, Lalloo UG |title=Accelerated silicosis in a foundry shotblaster. A case report |journal=S. Afr. Med. J. |volume=73 |issue=2 |pages=128–30 |year=1988 |month=January |pmid=3340919 |doi= |url=}}</ref>
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| * [[Thyroid cancer]]
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| * [[Thyrotoxicosis]]
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| * [[Tuberculosis]]
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| * [[Ulcerative colitis]]
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| * [[Vascular anomalies]]
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| ==Epidemiology and Demographics==
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| The exact frequency of clubbing in the population is not known. A 2008 study found clubbing in 1% of all patients admitted to a department of [[internal medicine]]. Of these, 40% turned out to have significant underlying disease of various causes, while 60% had no medical problems on further investigations and remained well over the subsequent year.<ref>{{cite journal |author=Vandemergel X, Renneboog B |title=Prevalence, aetiologies and significance of clubbing in a department of general internal medicine |journal=Eur. J. Intern. Med. |volume=19 |issue=5 |pages=325–9 |year=2008 |month=July |pmid=18549933 |doi=10.1016/j.ejim.2007.05.015}}</ref>
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| ==Diagnosis== | | ==Diagnosis== |
| | [[Clubbing history and symptoms|History and Symptoms]] | [[Clubbing physical examination|Physical Examination]] | [[Clubbing laboratory findings|Laboratory Findings]] | [[Clubbing electrocardiogram|Electrocardiogram]] | [[Clubbing chest x ray|X Rays]] | [[Clubbing CT|CT]] | [[Clubbing echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Clubbing other diagnostic studies|Other Diagnostic Studies]] |
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| ===Symptoms=== | | ==Treatment== |
| | | [[Clubbing medical therapy|Medical Therapy]] |
| Symptoms of the development of clubbing occur in five steps. They are as follows:<ref name=Myers>{{cite journal | author=Myers KA, Farquhar DR | title=The rational clinical examination: does this patient have clubbing? | journal=JAMA | year=2001 | volume=286 | pages=341–7 | pmid=11466101 | url= | doi=10.1001/jama.286.3.341}}</ref>
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| # Fluctuation and softening of the nail bed (increased ballotability)
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| # Loss of the normal <165° angle ("''Lovibond angle''") between the nailbed and the fold (''cuticula'')
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| # Increased convexity of the nail fold
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| # Thickening of the whole [[distal]] (end part of the) finger (resembling a drumstick)
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| # Shiny aspect and [[striation]] of the nail and skin
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| ===Physical Examination=== | | ==Case Studies== |
| When clubbing is encountered in patients, doctors will seek to identify its cause. They usually accomplish this by obtaining a [[anamnesis|medical history]]— particular attention is paid to lung, heart, and gastrointestinal conditions —and conducting a [[clinical examination]], which may disclose associated features relevant to a diagnosis.
| | [[Clubbing case study one|Case #1]] |
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| ====Heart==== | | ==Related Chapters== |
| Particular attention is paid to the heart in patients that present with digital clubbing.
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| ====Lungs====
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| Particular attention is paid to the lungs in patients that present with digital clubbing.
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| ====Abdomen====
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| Particular attention is paid to the abdomen because the doctor will be checking for [[gastrointestinal]] conditions that may be associated with digital clubbing.
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| ===Other Diagnostic Studies===
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| ''Schamroth's test'' or ''Schamroth's window test'' (originally demonstrated by South African cardiologist Dr Leo Schamroth on himself<ref>{{cite journal |author=Schamroth L |title=Personal experience |journal=S. Afr. Med. J. |volume=50 |issue=9 |pages=297–300 |year=1976 |month=February |pmid=1265563}}</ref>) is a popular test for clubbing. When the distal [[phalanges]] (bones nearest the fingertips) of corresponding fingers of opposite hands are directly [[wikt:appose|apposed]] (placed against each other back to back), a small diamond-shaped "window" is normally apparent between the nailbeds. If this window is obliterated, the test is positive and clubbing is present.
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| <gallery>
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| Image:Clubbing.png|Clubbing of the fingernail. The red line shows the outline of a clubbed nail.
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| </gallery>
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| The following image shows a bone scan of a person with a special form of clubbing called HPOA.
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| [[Image:Marie-Bamberger2.jpg|thumb|left|[[Bone scan]] of a patient with ''Marie-Bamberger syndrome'']]{{clr}}
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| ==See also==
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| * [[Periosteal reaction]] for more on HPOA and primary HOA | | * [[Periosteal reaction]] for more on HPOA and primary HOA |
| * [[Clubbed thumb]] | | * [[Clubbed thumb]] |
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| ==References==
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| {{reflist|2}}
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| [[es:Acropaquia]] | | [[es:Acropaquia]] |
