0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
The Rational Clinical Examination |

Does This Patient Have Clubbing?

Kathryn A. Myers, MD, EdM, FRCPC; Donald R. E. Farquhar, MD, SM, FRCPC
JAMA. 2001;286(3):341-347. doi:10.1001/jama.286.3.341.
Text Size: A A A
Published online

Context  The association between digital clubbing and a host of diseases has been recognized since the time of Hippocrates. Although the features of advanced clubbing are familiar to most clinicians, the presence of early clubbing is often a source of debate.

Objective  To perform a systematic review of the literature for information on the precision and accuracy of clinical examination for clubbing.

Data Sources  The MEDLINE database from January 1966 to April 1999 was searched for English-language articles related to clubbing. Bibliographies of all retrieved articles and of standard textbooks of physical diagnosis were also searched.

Study Selection  Studies selected for data extraction were those in which quantitative or qualitative assessment for clubbing was described in a series of patients. Sixteen studies met these criteria and were included in the final analysis.

Data Extraction  Data were extracted by both authors, who independently reviewed and appraised the quality of each article. Data extracted included quantitative indices for distinguishing clubbed from normal digits, precision of clinical examination for clubbing, and accuracy of clubbing as a marker of selected diseases.

Data Synthesis  The profile angle, hyponychial angle, and phalangeal depth ratio can be used as quantitative indices to assist in identifying clubbing. In individuals without clubbing, values for these indices do not exceed 176°, 192°, and 1.0, respectively. When clinicians make a global assessment of clubbing at the bedside, interobserver agreement is variable, with κ values ranging between 0.39 and 0.90. Because of the lack of an objective diagnostic criterion standard, accuracy of physical examination for clubbing is difficult to determine. The accuracy of clubbing as a marker of specific underlying disease has been determined for lung cancer (likelihood ratio, 3.9 with phalangeal depth ratio in excess of 1.0) and for inflammatory bowel disease (likelihood ratio, 2.8 and 3.7 for active Crohn disease and ulcerative colitis, respectively, if clubbing is present).

Conclusions  We recommend use of the profile angle and phalangeal depth ratio as quantitative indices in identifying clubbing. Clinical judgment must be exercised in determining the extent of further evaluation for underlying disease when these values exceed 180° and 1.0, respectively.

Figures in this Article

Topics

clubbing

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Figures

Figure. Appearance on Inspection for Clubbing
Graphic Jump Location
A, Normal finger viewed from above and in profile, and the changes occurring in established clubbing, viewed from above and in profile. B, The finger on the left demonstrates normal profile (ABC) and normal hyponychial (ABD) nail-fold angles of 169° and 183°, respectively. The clubbed finger on the right shows increased profile and hyponychial nail-fold angles of 191° and 203°, respectively. C, Distal phalangeal finger depth (DPD)/interphalangeal finger depth (IPD) represents the phalangeal depth ratio. In normal fingers, the IPD is greater than the DPD. In clubbing, this relationship is reversed. D, Schamroth sign: in the absence of clubbing, opposition of the index fingers nail-to-nail creates a diamond-shaped window (arrowhead). In clubbed fingers, the loss of the profile angle due to the increase in tissue at the nail bed causes obliteration of this space (arrowhead).

Tables

References

Letters

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 38

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Related Content

Customize your page view by dragging & repositioning the boxes below.

Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination
Make the Diagnosis: Clubbing

The Rational Clinical Examination
Original Article: Does This Patient Have Clubbing?

brightcove.createExperiences();