Monday, 5 February 2007

Nails-- The Looking Glass Into The Body

Splinter Haemorrhages

Good day to you all and I must say what glorious sunny weather we are now having this month-- only February and I have already seen trees producing blossom! That is global warming!

As for Nails, well these are something that are almost entirely missed out from the physical examination findings , as nails are simply not looked at by most junior doctors.

I sometimes take a long time looking at nails, as they can sometimes give the diagnosis!

For example, Splinter Haemorrhages can signify endocarditis (more than 6 are significant). Clubbing can lead the physician to look for one of the many causes of this physical finding.

Moreover, finding Beau's Lines (a horizontal depression / line across the nail signifying nail growth arrest) can semi-quantitively date the time of the onset of the illness. The nails of the hand growth at 0.1mm/day = 1mm per 10 days. Hence, measuring from the line to the nail fold in millimetres and multiplying by 10 will provide the period of onset of the illness in days.

Nails can reveal the cause of a rare form of arthritis and a relatively common skin condition which include psoriatic arthritis and psoriasis respectively. For example, a patient may have a substantial thickening of the nail bed (subungual hyperkeratosis), the nail may become weak and break off from the nail bed (onycholysis), the nail may have many longitudinal lines and small 'pits' in the nail like a thimble used for sowing, so-called Nail Pitting.

Nails can reveal Aortic Regurgitation via Quinke's sign-- the in-out movement of blood in the interface between the white and pink areas of the nail due to the raised pulse pressure associated with this condition. It is quite rare to see it, but I have seen it 3 times in my career!!

Nail changes may also be seen in some inherited diseases such as the Polyendocrine Deficiency, Yellow Nail Syndrome etc....

Hence checking the nails can be a very important thing to do.

Clubbing-- should never be forgotten, but the causes cover many different systems.

Clubbing of a Patient's Fingers with Fibrotic Lung Disease


  • Infective: Infective Endocarditis
  • Genetic/Developmental : Cyanotic Heart Disease
  • Cancer: Atrial Myxoma
  • Infective: TB, Empyema, Lung Abscess, Pneumonia, Bronchiectasis
  • Cancer: Primary Lung Cancer, Mesothelioma
  • Inflammatory: Fibrosing Alveolitis / CFA
  • Genetic: Cystic Fibrosis (from repeated suppurative chest infections)
  • Inflammatory: Crohn's Disease, Ulcerative Colitis
  • Malignancy: Lymphoma
  • Metabolic: Chronic Liver Disease
  • Malabsorptive: Coeliac Disease
Also Remember:

FAMILIAL (a friend of mine has congenital clubbing!!)

  • Axillary artery aneurysm
  • Brachial arterio-venous malformations

Clubbing of a Patient's Toes!!

My Normal Finger

Normal 'diamond-shape' when both index fingers are put together as mirror images. The diamond is normally produced but this diappears with Clubbing.