First step for examination of clubbing is
Bring the patient's lingers at examiners eye level and look tangentially.You should observe the onychodermal angle. If the angle is 180° or more, it is said that clubbing is present.
Second step for examination of clubbing
Very early clubbing can be detected by increase in fluctuation of the nail-bed it is due to softening of the nail-bed. To elicit 'fluctuation', the patient's finger (index finger) is placed on the pulp of examiner's two thumbs and held in this position by gentle pressure with the tips of examiner’s middle fingers applied on the patient's proximal interphalangeal joint. The patient's finger is now palpated over the base of the nail by the tips of examiner's index fingers. There is always some amount of fluctuation is present in normal fingers. Clubbing is said to be present when fluctuation is obvious here the palpation of the nail-bed may give the impression that the nail is floating on its bed.
For detection of clubbing, you should first examine the onychodermal angle and then the fluctuation.
What is the most reliable early sign of clubbing ?
Loss of normal onychodermal angle is one of the earliest sign is of clubbing increased fluctuation of the nail-bed although occur early is not always reliable.
Which fingers are affected first in clubbing ?
Usually the index finger is affected first in clubbing
What are the points to note when clubbing is detected?
- Unilateral or bilateral.
- Painful or not.
- Presence or absence of central cyanosis.
- Presence or absence of dyspnoea.
- The degree of clubbing.
Grade 1-Increased fluctuation of nailbed which lead to increased looseness of base of nail
Grade 2-Obliteration of nailbed angle more than or equal to 180 . It can be demonstrated by keeping the finger in profile view this is called profilesign
Grade 3-Parrot beaking—Biconvexity of nail
Grade 4-Drumstick nail-Bulbous enlargement of distal portion of fingers and toes
Grade 5-Hypertrophic osteoarthropathy-with the above mentioned features plus
- Thickening of periosteum
- Distal arthropathy
- Periosteal tenderness and heaviness of hands