Drumstick fingers or watchglass nails are convex nails and terminal phalanges, which are associated with internal disorders associated with insufficient blood flow (ischemia). The underlying mechanism of drumstick fingers or watch glass nails is unknown as of 2023. If you notice thickenings on the fingertips and bulging nails, it is wise to consult your doctor. Treatment for drumstick fingers or watchglass nails is dictated by the underlying disease process. Drumstick fingering is potentially reversible if the underlying condition is treated early enough, but the changes may be irreversible once collagen deposition has initiated.

• What are drumstick fingers
• Synonyms
• How often does it happen?
• Symptoms
• Phases
• Causes of watch glass nails

• Decreased oxygen level
• Chronic lung problems and heart disease

• Lung diseases
• Heart disease
• Gastrointestinal disorders and liver diseases
• Cancer
• Other causes of drumstick fingers

• Innate form
• Hypertrophic osteoarthropathy
• Primary hypertrophic osteoarthropathy (PHO)

• Examination and diagnosis
• Treatment of drumstick fingers
• Forecast and prospects
• Prevention

What are drumstick fingers

Drumstick fingers or watchglass nails were described in ancient times by Hippocrates (a Greek physician and founder of Western medicine) and is a clinical sign of a number of different disease processes (internal disorders). In drumstick fingers, the fingertips are broadened and the nails are shiny and convex. The exact mechanism that leads to drumstick fingering is poorly understood as of 2023, although it is known to develop most often in people with heart and lung conditions that reduce the total amount of oxygen in the blood. However, drumstick fingering may also be associated with malignancies and some gastrointestinal disorders. Drumstick fingering can have a slow onset to the point where you are not aware of the change. It is usually painless but is sometimes accompanied by discomfort or pain in the fingertips. Rare skin conditions such as pachydermoperiostosis and palmoplantar keratoderma are rare causes of drumstick fingers.

Synonyms

Drumstick fingers is also known by the following names:

• club bed fingers
• drumstick fingers
• Hippocratus fingers
• Hippocrates nails
• watch glass nails
• watch glass nails

How often does it happen?

The exact frequency of drumstick fingering is unknown in 2023.Drumstick fingers / Source: Desherinka, Wikimedia Commons (GFDL)

Symptoms

Drumstick fingers or watchglass nails symptoms include:

• a deformity of the end of the fingers
• the fingertips are thickened
• the cuticles disappear
• the nails run convex around the fingertips (convex nails)
• usually both hands are affected
• sometimes pain

Drumstick fingering affects both hands. The thickening of the fingertips or toes occurs over time and may not even be noticed by the person. In drumstick fingers, the layer of cells under the nails becomes soft. The nails sometimes appear to move. The nail comes to the cuticle at a sharper angle. Each affected nail curves around the finger and resembles the round part of an inverted spoon or a watch glass.

Phases

Drumstick fingering can be present in one of five stages:

1. No visible drumstick fingers: shiny nails and softening of the nail bed. No visible changes in nails.
2. Mild drumstick fingers: Loss of the normal <165° angle (Lovibond angle) between the nail bed and the fold (cuticle). Schamroth’s window is obliterated.* Drumstick fingers is not immediately apparent.
3. Moderate drumstick fingers: increased convexity (bulging) of the nail fold. Drumstick fingers is obvious at a glance.
4. Severe drumstick fingers: thickening of the entire distal (end part of the) finger (resembling a drumstick).
5. Hypertrophic osteoarthropathy – Shiny appearance and typical widening of the fingertips and curving of the nails.

(*) In people without eardrum fingers, when you place two of the same fingers with their nails together, a diamond-shaped window is observed. In people with drumstick fingers, this window usually disappears and this phenomenon is known as the ‘ Shamroth test ‘.

Causes of watch glass nails

Decreased oxygen level

A specific cause of drumstick fingers or watch glass nails is not known as of 2023. Generally, this phenomenon occurs in lung and heart diseases that reduce the oxygen level in the blood, such as:

• congenital heart disease
• chronic lung infections caused by bacteria or fungi
• bacteria or fungi that infect the inner lining of the heart and heart valves
• lung diseases with swelling and scarring in the lungs

Chronic lung problems and heart disease

More than three-quarters of cases are related to chronic lung problems. Cardiovascular disease (heart and blood vessels) plays a role in roughly 15% of cases. And about 10 percent are associated with constantly recurring liver and stomach diseases. Drumstick fingers or watchglass nails may also be linked to a number of other conditions, such as celiac disease, dysentery (a severe form of diarrhea, often causing blood and mucus in the stool), hyperthyroidism (an overactive thyroid gland) and some forms of cancer, such as liver cancer and stomach cancer.Lung cancer / Source: Muratart/Shutterstock.com

Lung diseases

Drumstick fingers or watchglass nails is associated with the following lung diseases:

• Lung cancer, mainly non-small cell (54% of all cases), not commonly seen with small cell lung cancer (<5% of cases).
• Interstitial lung disease, more than 150 different lung diseases that affect the interstitium (the space between the alveoli and blood vessels), most commonly idiopathic pulmonary fibrosis (IPF).
• Complicated tuberculosis (TB).
• Suppurative lung diseases: lung abscess, pleural empyema (accumulation of pus in the pleural space or pleural cavity), bronchiectasis (where parts of the lungs are constantly dilated and irritated), cystic fibrosis (CF, cystic fibrosis).
• Mesothelioma (a malignant) tumor of the pleura.
• Arteriovenous fistulas or malformations (an abnormal connection between an artery and a vein).
• COPD (collective name for emphysema and chronic bronchitis).

Drumstick fingers or watchglass nails is not specific to chronic obstructive pulmonary disease (COPD). Therefore, in patients with COPD who have a significant degree of drumstick fingers, it may be useful to look for possible signs of other causes.

Heart disease

Heart disease can also cause drumstick fingers:

• Any disease with chronic hypoxia (a condition of oxygen deficiency, in which tissues in the body as a whole or in a specific part of the body are not supplied with sufficient oxygen).
• Congenital cyanotic heart disease (most common cardiac cause and concerns congenital heart disease in which a newborn has central cyanosis (cyanosis).
• Subacute bacterial endocarditis (inflammation of the inner lining of the heart and heart valves).
• Myxoma cordis (an intracardiac tumor, which occurs in the heart).
• Tetralogy of Fallot (a congenital heart defect).

Gastrointestinal disorders and liver diseases

There are also certain gastrointestinal and liver diseases that can lead to drumstick fingers or watchglass nails:

• Malabsorption (deficient digestion or absorption of nutrients).
• Inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis.
• Liver cirrhosis, especially in primary biliary cirrhosis (PBC, where the small bile ducts in the liver are chronically inflamed).
• Hepatopulmonary syndrome, a complication of cirrhosis.

 The thymus is located behind the sternum / Source: Nerthuz/Shutterstock.com

Cancer

Drumstick fingers can also be caused by some cancers, such as:

• Thyroid cancer.
• Stomach cancer.
• Liver cancer.
• Thymic cancer (cancer of the thymus, a gland in the chest).
• Hodgkin’s disease.
• Disseminated chronic myelogenous leukemia (a form of blood cancer).

Other causes of drumstick fingers

Other conditions that can lead to drumstick fingers include:

• Graves’ disease (autoimmune hyperthyroidism).
• Familial and racial drumstick fingering and pseudo-drumstick fingering (people of African descent are more susceptible to it).
• Vascular malformations (vascular abnormalities) of the affected arm, such as an aneurysm of the axillary vein (in single-sided drumstick fingers).

Innate form

A congenital form is also known. This can be inherited in an autosomal recessive or autosomal dominant manner. In these cases the thumbs are almost always affected; the other fingers may also be affected.

Hypertrophic osteoarthropathy

A special form of clubbing is hypertrophic osteoarthropathy (Pierre Marie-Bamberger disease). This is the combination of drumstick fingers and thickening of periosteum (connective tissue lining of the bones) and synovium (lining of joints), and is often initially diagnosed as arthritis. It is often associated with lung cancer.

Primary hypertrophic osteoarthropathy (PHO)

Primary hypertrophic osteoarthropathy (PHO) has no signs of lung disease. This form has a hereditary component, although subtle heart defects can sometimes be found. It is also known as Touraine-Solente-Gole syndrome. This condition is linked to mutations in the gene on the fourth chromosome (4q33-q34) that codes for the enzyme 15-hydroxyprostaglandin dehydrogenase (HPGD); this leads to reduced breakdown of prostaglandin E2 and increased levels of this substance.

Examination and diagnosis

The doctor will perform a physical examination and ask questions about your health and possible other complaints. In addition, blood tests or urine tests may be required. Imaging tests will often also be used if heart or lung disease is suspected. Taking X-rays or a CT scan or MRI scan can provide clarity about the underlying cause.

Treatment of drumstick fingers

The treatment will focus on the underlying disease process.

Forecast and prospects

In some cases, your toenail and fingernails may return to their normal shape once the underlying medical condition is adequately treated. Some conditions that cause drumstick fingers can be cured, others are chronic but treatable, and some are more difficult to treat.

Prevention

The only way to prevent drumstick finger is to take steps to prevent and manage the underlying conditions that can cause it. For example, you can reduce the risk of lung cancer by not smoking and limiting exposure to toxins in the workplace. Reduce the risk of developing bronchiectasis by getting vaccinated against measles and whooping cough, consulting a doctor immediately for lung infections and limiting tobacco smoke and other toxins. If you have been diagnosed with lung disease, follow the doctor’s recommended treatment plan. This can help keep the oxygen level in the blood at a good level and prevent drumstick fingers.

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