Grading of Clubbing
                     GRADING OF CLUBBING
INTRODUCTION
Digital clubbing has been regarded as an 
ominous sign through centuries, often 
signifying the presence of a dreadful internal 
illness. Clubbing is described as bulbous 
uniform swelling of the terminal phalanx of a 
digit. Proliferation and edema of connective 
tissue leads to a loss of the normal angle 
between the nail and the nail bed
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EPIDEMIOLOGY
Exact frequency of clubbing due to various 
causes remains unknown. It is said to be 
present in 1% of internal medicine 
admissions and associated with serious 
disease in nearly 40%.
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 HISTORY
Digital clubbing is regarded as the oldest 
clinical sign in medicine. Clubbing was 
probably first described by Hippocrates in 
the 5th century BC in association with 
chronic empyema. 
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 PATHOPHYSIOLOGY
No single theory can explain all causes of 
clubbing. Vascular endothelial growth factor 
is said to play a key role. Produced in 
diverse malignancies and stimulated by 
hypoxia, it is known to induce vascular 
hyperplasia, edema, and fibroblast or 
osteoblast proliferation leading to clubbing.
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FOUR GRADES
• Fluctuation is positive due to the increased 
proliferation of cells at the nail base with 
obliteration of onychodermal angle
• Grade 1+ – increased anteroposterior and 
transverse diameters of nails
• Grade 2+ – increase in pulp tissue resulting 
in Parrot's beak or drumstick appearance
• Grade 3+ – HOA.
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CLINICAL 
SIGNIFICANCE
Clubbing or HOA may provide the first 
clinical indication of an underlying serious 
illness. However, it is easily overlooked on 
routine clinical examination. The 
development of clubbing takes years though 
occasionally it develops suddenly.
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PROGNOSIS
Clubbing has been considered to be a poor 
prognostic sign, meaning the illness is in an 
advanced stage.  This has been shown in 
patients with sickle cell anemia, pulmonary 
fibrosis, asbestosis, cystic fibrosis, Graves' 
disease, hypersensitivity pneumonitis, and 
TB.
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 CONCLUSION
The value of clubbing as a distinct clinical 
sign with all its remarkable features always 
makes an interesting discussion. Its value as 
a window to internal medicine cannot be 
over exaggerated. It has mesmerized 
clinicians for centuries and rightly so.
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THANK YOU