Drumstick syndrome on the legs. Drum fingers

Syndrome drumsticks- not an independent disease, but a rather informative sign of other diseases and pathological symptoms.

Reasons

The true reasons why drumstick-shaped fingers develop in long-term smokers and in those suffering from pulmonary and cardiac pathologies is not yet clear. It is believed that the reasons lie in the violation humoral regulation under the influence of provoking factors, including chronic hypoxia. Provocateurs of development this symptom There may be pulmonary diseases: lung cancer, chronic pulmonary intoxication, bronchiectasis, lung abscess, fibrosis.

Drumsticks are often found in patients suffering from liver cirrhosis, Crohn's disease, esophageal tumors, and esophagitis. Lymphoma, myeloid leukemia, infective endocarditis, heart defects and hereditary causes can also cause the fingers to take on the appearance of drumsticks.

Symptoms

The finger-drumstick symptom occurs at first unnoticed by the patient, since it does not cause pain, and changes are not so easy to notice. Thicken first soft fabrics on the terminal phalanges of the fingers (usually hands). The bone tissue is not changed. As the distal phalanges increase, the fingers become more and more like drumsticks, and the nails take on the appearance of watch glasses.

If you press on the base of the nail, you will get the impression that the nail is about to come off. In fact, a layer of pliable spongy tissue has formed between the nail and the phalanx bone, which creates the feeling of looseness of the nail plate. Subsequently, the changes become more noticeable and rougher, and when the fingers are brought together, the so-called “Shamroth window” disappears.

Diagnosis and treatment

X-ray and bone scintigraphy will help determine whether these are really drumstick-shaped fingers and not congenital hereditary osteoarthropathy.

When this symptom appears, a complete and thorough examination of the patient is necessary to determine the source of this symptom. Etiotropic treatment can be different - depending on the reason that led to the development of drumstick fingers.

Forecast

It depends solely on the reason that led to its development. If drumstick fingers have developed due to a disease that can be cured or put into stable remission, then a reverse development of symptoms, including drumstick fingers and watch glass nails, is possible.

“Drumstick” syndrome is a clearly marked thickening of the nail plates in a convex shape, vaguely reminiscent of curved watch glasses. From a distance, it seems that the tips of a person’s finger seem to have inflated huge balls, which are found in certain species of aquatic frogs, or they are wearing a round thimble. Due to its resemblance to the surface of a dial, the disease is often called “watch glass” syndrome.

How?

The above-described transformation of the nail surface occurs as a result of modification of the tissue lying between nail plate and bone. The tissue grows, but the bone itself remains unchanged.

“Drumsticks” can occur on both the arms and legs. However, in most cases, like a fish rotting from the head, the syndrome begins to develop from the fingers. At the very beginning of the disease, the angle between the nail plate and the posterior nail fold (known as the “Lovibond angle”) becomes approximately one hundred and eighty degrees, subsequently increasing (it is worth noting that the norm is one hundred and sixty degrees). On late stages development nail phalanges protrude almost half the size of the nail. This is accompanied by a feeling of constant discomfort.

When?

Drumstick syndrome can occur at any age. If similar disease child suffers, it is most likely caused by some birth defect(often leads to it, for example, heart disease). In an adult, “watch glass” syndrome can occur as a result of several types of diseases: pulmonary, gastrointestinal, cardiovascular. There is a high risk of developing “drumsticks” in heavy smokers, since the lungs of this group of people are quite weak. People suffering from liver cirrhosis, bronchogenic lung cancer, various chronic purulent lung diseases, and cystic fibrosis can also be considered at risk.

If you notice such symptoms, you should immediately consult a doctor to undergo a full medical examination and identify the cause of the disease. At the Pulmonology Center clinic you will be provided with quality care and comprehensive inspection, because to treat this problem it is vital to accurately determine its root cause. In the hospital, you must have an x-ray to determine whether this is really the syndrome described above or a consequence of congenital hereditary osteoarthropathy, the fundamental difference of which is the transformation of the bone.

Diagnostics:

Treatment:

The doctor can pick individual program treatment based on results laboratory research, diagnosis and severity of the disease. The doctor may prescribe antibiotics, anti-inflammatory, immunomodulatory, antiviral drugs, as well as vitamin therapy, physiotherapy, diet, infusion or drainage therapy. The main thing for you: apply for timely medical care to the “Pulmonology Center” to experienced specialists to find out the reasons that resulted in the appearance of “watch glasses”.

Note:

Drumstick syndrome is often called “Hippocrates' fingers,” but the famous ancient Greek physician did not have such a disease. Hippocrates was simply the first scientist to describe this disease, and for more than two thousand years of history, medicine has skillfully dealt with “watch glasses.”

Poteyko P.I., Kharkovskaya medical academy Postgraduate Education, Department of Phthisiology and Pulmonology

Even in ancient times, 25 centuries ago, Hippocrates described changes in the shape of the distal phalanges of the fingers, which occurred in chronic pulmonary pathology (abscess, tuberculosis, cancer, pleural empyema), and called them “drum sticks.” Since then, this syndrome has been called by his name - Hippocratic fingers (Hippocratic fingers) (digiti Hippocratici).

Hippocratic finger syndrome includes two signs: “hour glass” (Hippocratic fingernails - ungues Hippocraticus) and club-shaped deformation of the terminal phalanges of the fingers like “drumsticks” (Finger clubbing).

Currently, PG is considered the main manifestation of hypertrophic osteoarthropathy (HOA, Marie-Bamberger syndrome) - multiple ossifying periostosis.

The mechanisms of development of PG are currently not fully understood. However, it is known that the formation of PG occurs due to a violation of microcirculation, accompanied by local tissue hypoxia, impaired trophism of the periosteum and autonomic innervation against the background of prolonged endogenous intoxication and hypoxemia. In the process of formation of PG, the shape of the nail plates (“hour glasses”) first changes, then the shape of the distal phalanges of the fingers changes into a club-shaped or flask-shaped shape. The more pronounced the endogenous intoxication and hypoxemia, the more severely the terminal phalanges of the fingers and toes are modified.

Changes in the distal phalanges of the fingers according to the “drumstick” type can be established in several ways.

It is necessary to identify a smoothing of the normally existing angle between the base of the nail and the nail fold. The disappearance of the “window”, which is formed when the distal phalanges of the fingers are compared with their dorsal surfaces facing each other, is the most early sign thickening of the terminal phalanges. The angle between the nails does not normally extend upward more than half the length of the nail bed. As the distal phalanges of the fingers thicken, the angle between the nail plates becomes wide and deep (Fig. 1).

On unmodified fingers, the distance between points A and B should exceed the distance between points C and D. With “drumsticks” the relationship is the opposite: C - D becomes longer than A - B (Fig. 2).

Another important sign PG is the value of the angle ACE. On a normal finger this angle is less than 180°; with “drumsticks” it is more than 180° (Fig. 2).

Along with the “fingers of Hippocrates,” in paraneoplastic Marie-Bamberger syndrome, periostitis appears in the area of ​​the end sections of long tubular bones (usually the forearms and legs), as well as the bones of the hands and feet. In places of periosteal changes, severe ossalgia or arthralgia and local palpation pain may be observed, with x-ray examination a double cortical layer is revealed, due to the presence of a narrow dense strip separated from the compact bone substance light gap (symptom of “tram rails”) (Fig. 3). It is believed that Marie-Bamberger syndrome is pathognomonic for lung cancer; less often it occurs in other primary intrathoracic tumors ( benign neoplasms lungs, pleural mesothelioma, teratoma, mediastinal lipoma). Rarely, this syndrome occurs in cancer. gastrointestinal tract, lymphoma with metastases to the lymph nodes of the mediastinum, lymphogranulomatosis. At the same time, Marie-Bamberger syndrome also develops in non-oncological diseases - amyloidosis, chronic obstructive pulmonary disease, tuberculosis, bronchiectasis, congenital and acquired heart defects, etc. One of distinctive features of this syndrome in non-tumor diseases there is a long-term (over a period of years) development of characteristic changes in the osteoarticular apparatus, while in malignant neoplasms this process is calculated in weeks and months. After radical surgical treatment Cancer Marie-Bamberger syndrome can regress and completely disappear within a few months.

Currently, the number of diseases in which changes in the distal phalanges of the fingers are described as “drumsticks” and nails as “watch glasses” has increased significantly (Table 1). The appearance of PG often precedes more specific symptoms. We especially need to remember the “sinister” connection of this syndrome with lung cancer. Therefore, identifying signs of PG requires correct interpretation and instrumental and laboratory methods examinations for timely establishment of a reliable diagnosis.

The relationship between PG and chronic lung diseases accompanied by long-term endogenous intoxication And respiratory failure(DN), is considered obvious: their formation is especially often observed when pulmonary abscesses- 70–90% (within 1–2 months), bronchiectasis - 60–70% (within several years), pleural empyema - 40–60% (within 3–6 months or more) (“rough” fingers Hippocrates, Fig. 4).

In tuberculosis of the respiratory organs, PGs are formed in the case of a widespread (more than 3–4 segments) destructive process with a long or chronic course(6–12 months or more) and are characterized mainly by the “watch glass” symptom, thickening, hyperemia and cyanosis of the nail fold (“delicate” Hippocratic fingers - 60–80%, Fig. 5).

In idiopathic fibrosing alveolitis (IFA), PG occurs in 54% of men and 40% of women. It has been established that the severity of hyperemia and cyanosis of the nail fold, as well as the very presence of PG, indicate in favor of poor prognosis with ELISA, reflecting, in particular, the prevalence of active damage to the alveoli (ground glass areas detected with computed tomography) and the severity of vascular proliferation smooth muscle cells in foci of fibrosis. PG is one of the factors that most reliably indicates a high risk of the formation of irreversible pulmonary fibrosis in patients with IFA, which is also associated with a decrease in their survival.

At diffuse diseases connective tissue involving the pulmonary parenchyma, PH always reflect the severity of DN and are an extremely unfavorable prognostic factor.

For other interstitial lung diseases, the formation of PG is less typical: their presence almost always reflects the severity of DN. J. Schulze et al. described this clinical phenomenon in a 4-year-old girl with rapidly progressive pulmonary histiocytosis X. V. Holcomb et al. revealed changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” in 5 out of 11 patients examined with pulmonary veno-occlusive disease.

As lung lesions progress, PGs appear in at least 50% of patients with exogenous allergic alveolitis. The leading importance should be emphasized persistent decline partial pressure of oxygen in the blood and tissue hypoxia in the development of HOA in patients suffering from chronic lung diseases. Thus, in children with cystic fibrosis, the partial pressure of oxygen in arterial blood and forced expiratory volume in 1 second were the smallest in the group with the most pronounced changes distal phalanges of fingers and nails.

There are isolated reports of the appearance of PG in bone sarcoidosis (J. Yancey et al., 1972). We observed more than a thousand patients with intrathoracic sarcoidosis lymph nodes and lungs, including skin manifestations, and in no case was the formation of PG detected. Therefore, we consider the presence/absence of PG as a differential diagnostic criterion for sarcoidosis and other pathologies of the chest organs (fibrosing alveolitis, tumors, tuberculosis).

Changes in the distal phalanges of the fingers like “drum sticks” and nails like “watch glasses” are often recorded when occupational diseases occurring with the involvement of the pulmonary interstitium. Relatively early appearance of GOA is typical for patients with asbestosis; this sign is in favor of high risk death. According to S. Markowitz et al. , during a 10-year follow-up of 2709 patients with asbestosis, with the development of PG, their probability of death increased by at least 2 times.
PGs were detected in 42% of the examined coal mine workers who suffered from silicosis; In some of them, along with diffuse pneumosclerosis, foci of active alveolitis were found. Changes in the distal phalanges of the fingers like “drumsticks” and nails like “watch glasses” have been described in workers of factories producing matches who were in contact with rhodamine used in their production.

The connection between the development of PH and hypoxemia is confirmed by the repeatedly described possibility of the disappearance of this symptom after lung transplantation. In children with cystic fibrosis, characteristic changes in the fingers regressed during the first 3 months. after lung transplantation.

The appearance of PG in a patient with interstitial lung disease, especially with a long history of the disease and in the absence of clinical signs of active lung damage, requires a persistent search for a malignant tumor in the lung tissue. It has been shown that in lung cancer that developed against the background of ELISA, the frequency of GOA reaches 95%, while in cases of damage to the pulmonary interstitium without signs of neoplastic transformation, it is found more rarely - in 63% of patients.

The rapid development of changes in the distal phalanges of the fingers like “drum sticks” is one of the indications for the development of lung cancer even in the absence of precancerous diseases. IN similar situation clinical signs of hypoxia (cyanosis, shortness of breath) may be absent and this sign develops according to the laws of paraneoplastic reactions. W. Hamilton et al. demonstrated that the likelihood of a patient having PG increases by 3.9 times.

GOA is one of the most common paraneoplastic manifestations of lung cancer; its prevalence in this category of patients can exceed 30%. The dependence of the frequency of detection of PG on the morphological form of lung cancer is shown: reaching 35% in the non-small cell variant, in the small cell variant this figure is only 5%.

The development of HOA in lung cancer is associated with hyperproduction of growth hormone and prostaglandin E2 (PGE-2) by tumor cells. The partial pressure of oxygen in the peripheral blood may remain normal. It was found that in the blood of patients with lung cancer with a symptom of PG, the level of transforming growth factor β (TGF-β) and PGE-2 significantly exceeds that of patients without changes in the distal phalanges of the fingers. Thus, TGF-β and PGE-2 can be considered relative inducers of PG formation, relatively specific for lung cancer; Apparently, this mediator is not involved in the development of the discussed clinical phenomenon in other chronic pulmonary diseases with DN.

The paraneoplastic nature of the “drumstick” type changes in the distal phalanges of the fingers is clearly demonstrated by the disappearance of this clinical phenomenon after successful resection lung tumors. In turn, reappearance This clinical sign in a patient whose lung cancer treatment has been successful is a likely indication of tumor recurrence.

PG can be a paraneoplastic manifestation of tumors localized outside the lung area, and may even precede the first clinical manifestations malignant tumors. Their formation is described in malignant tumors of the thymus, cancer of the esophagus, colon, gastrinoma, characterized by clinically typical Zollinger-Ellison syndrome, and pulmonary artery sarcoma.

The possibility of PG formation in malignant breast tumors and pleural mesothelioma, which is not accompanied by the development of DN, has been repeatedly demonstrated.

PGs are detected in lymphoproliferative diseases and leukemia, including acute myeloblastic, in which they were noted on the arms and legs. After chemotherapy, which stopped the first attack of leukemia, the signs of GOA disappeared, but reappeared after 21 months. in case of tumor recurrence. In one of the observations, regression of typical changes in the distal phalanges of the fingers was stated with successful chemotherapy and radiation therapy lymphogranulomatosis.

Thus, PG, along with various types of arthritis, erythema nodosum and migratory thrombophlebitis, are among the frequent extra-organ, nonspecific manifestations of malignant tumors. The paraneoplastic origin of changes in the distal phalanges of the fingers like “drumsticks” can be assumed when they form quickly (especially in patients without DN, heart failure and in the absence of other causes of hypoxemia), as well as when combined with other possible extra-organ, nonspecific signs of a malignant tumor - an increase in ESR, changes in the peripheral blood picture (especially thrombocytosis), persistent fever, articular syndrome and recurrent thrombosis various localizations.

One of the most common reasons The appearance of PG is considered to be congenital heart defects, especially the “blue” type. Among 93 patients with pulmonary arteriovenous fistulas observed at the Mauo Clinic for 15 years, similar changes in the fingers were recorded in 19%; they exceeded the frequency of hemoptysis (14%), but were inferior to murmurs over the pulmonary artery (34%) and shortness of breath (57%).

R. Khouzam et al. (2005) described an ischemic stroke of embolic origin that developed 6 weeks after birth in an 18-year-old patient. The presence of characteristic changes in the fingers and hypoxia, which required respiratory support, led to a search for an anomaly in the structure of the heart: transthoracic and transesophageal echocardiography revealed that the lower vena cava opened into the cavity of the left atrium.

PGs can “discover” the existence of pathological shunting from the left side of the heart to the right, including that formed as a consequence cardiac surgery. M. Essop et al. (1995) observed characteristic changes in the distal phalanges of the fingers and increasing cyanosis for 4 years after balloon dilatation of rheumatic mitral stenosis, the complication of which was a small defect interatrial septum. During the period since the operation, its hemodynamic significance increased significantly due to the fact that the patient also developed rheumatic stenosis of the tricuspid valve, after correction of which these symptoms completely disappeared. J. Dominik et al. noted the appearance of PG in a 39-year-old woman 25 years after successful elimination atrial septal defect. It turned out that during the operation the inferior vena cava was mistakenly directed to the left atrium.

PG is considered one of the most typical nonspecific, so-called extracardiac, clinical signs infective endocarditis(IE). The frequency of changes in the distal phalanges of the fingers like “drumsticks” in IE can exceed 50%. Evidence in favor of IE in a patient with PG high fever with chills, increased ESR, leukocytosis; Anemia, a transient increase in serum activity of hepatic aminotransferases, and various types of kidney damage are often observed. To confirm IE, transesophageal echocardiography is indicated in all cases.

According to some clinical centers, one of the most common causes of the phenomenon of PG is cirrhosis of the liver with portal hypertension and progressive dilatation of the vessels of the pulmonary circulation, leading to hypoxemia (the so-called pulmonary-renal syndrome). In such patients, GOA is usually combined with cutaneous telangiectasias, often forming “fields of spider veins» .
A connection has been established between the formation of HOA in liver cirrhosis and previous alcohol abuse. In patients with liver cirrhosis without concomitant hypoxemia, PG is usually not detected. This clinical phenomenon is also characteristic of primary cholestatic liver lesions requiring liver transplantation. childhood, including when congenital atresia bile ducts.

Repeated attempts have been made to decipher the mechanisms of development of changes in the distal phalanges of the fingers like “drumsticks” in diseases, including those mentioned above (chronic lung diseases, congenital heart defects, IE, liver cirrhosis with portal hypertension), accompanied by persistent hypoxemia and tissue hypoxia. Hypoxia-induced activation of tissue growth factors, including platelet growth factors, plays a leading role in the formation of changes in the distal phalanges and fingernails. In addition, in patients with PG, an increase in serum level hepatocyte growth factor, as well as vascular factor growth. The connection between the increase in the activity of the latter and a decrease in the partial pressure of oxygen in arterial blood is considered the most obvious. Also, in patients with PH, a significant increase in the expression of hypoxia-inducible factors type 1a and 2a is found.

In the development of changes in the distal phalanges of the fingers of the “drumstick” type, endothelial dysfunction associated with a decrease in the partial pressure of oxygen in the arterial blood may have a certain significance. It has been shown that in patients with GOA, the serum concentration of endothelin-1, the expression of which is induced primarily by hypoxia, is significantly higher than that in healthy people.
The mechanisms of PG formation in chronic diseases are difficult to explain. inflammatory diseases intestines, for which hypoxemia is not typical. However, they are often found in Crohn's disease (with ulcerative colitis they are not typical), in which a “drumstick” type change in the fingers may precede the actual intestinal manifestations diseases.

Number probable causes, causing changes in the distal phalanges of the fingers like “watch glasses”, continues to increase. Some of them are very rare. K. Packard et al. (2004) observed the formation of PG in a 78-year-old man who took losartan for 27 days. This clinical phenomenon persisted when losartan was replaced by valsartan, which allows us to consider it undesirable reaction for the entire class of angiotensin II receptor blockers. After switching to captopril, changes in the fingers completely regressed within 17 months. .

A. Harris et al. found characteristic changes in the distal phalanges of the fingers in a patient with primary antiphospholipid syndrome, while no signs of thrombotic lesions of the pulmonary vascular bed were identified. The formation of PGs has also been described in Behçet's disease, although it cannot be completely ruled out that their appearance in this disease was accidental.
PGs are considered among possible indirect markers of drug use. In some of these patients, their development may be associated with a variant of lung damage or IE characteristic of drug addicts. Changes in the distal phalanges of the fingers like “drum sticks” are described in users of not only intravenous, but also inhaled drugs, for example, hashish smokers.

With increasing frequency (at least 5%), PG is registered in HIV-infected people. Their formation may be based on various forms of HIV-associated pulmonary diseases, but this clinical phenomenon is observed in HIV-infected patients with intact lungs. It has been established that the presence of characteristic changes in the distal phalanges of the fingers in HIV infection is associated with a lower number of CD4-positive lymphocytes in the peripheral blood; in addition, interstitial lymphocytic pneumonia is more often recorded in such patients. In HIV-infected children, the appearance of PG is a likely indication of pulmonary tuberculosis, which is possible even in the absence of Mycobacterium tuberculosis in sputum samples.

The so-called primary, not associated with diseases, is known internal organs a form of GOA, often familial (Touraine-Solant-Gole syndrome). It is diagnosed only after excluding most of the causes that can cause the appearance of PG. Patients with the primary form of GOA often complain of pain in the area of ​​the changed phalanges, increased sweating. R. Seggewiss et al. (2003) observed primary GOA involving only the fingers of the lower extremities. At the same time, when establishing the presence of PH in members of the same family, it is necessary to take into account the possibility that they have inherited congenital heart defects (for example, patent ductus botallus). The formation of characteristic changes in the fingers can continue for about 20 years.

Recognizing the causes of changes in the distal phalanges of the fingers according to the “drumstick” type requires differential diagnosis various diseases, among which the leading position is occupied by those associated with hypoxia, i.e. clinically manifested DN and/or heart failure, as well as malignant tumors and subacute IE. Interstitial lung diseases, primarily ELISA, are one of the most common causes of PG; the severity of this clinical phenomenon can be used to assess the activity of lung damage. The rapid formation or increase in the severity of GOA necessitates the search for lung cancer and other malignant tumors. At the same time, one should take into account the possibility of the appearance of this clinical phenomenon in other diseases (Crohn's disease, HIV infection), in which it can occur much earlier than specific symptoms.

Changing fingers that now resemble “drumsticks” - what is this? This is the growth of connective tissue of the distal phalanges of the fingers and toes. Changes are especially noticeable on the back of the fingers. Sometimes a person can have nails with an increased bulge. This in no way applies to “drumsticks”, because... “drumsticks” are the growth of soft tissues with the rise of the base of the nail and the disappearance of the subungual angle.

Such changes were first noticed in the time of Hippocrates; in the 19th century, hypertrophic osteoarthropathy was described, which was often combined with such a modification of the distal phalanges. Then a connection was established between the appearance of “drumsticks” and bronchogenic carcinoma, bronchial asthma, cystic fibrosis, lung abscess, endocarditis.

“Drumsticks” themselves are painless, although patients in some cases may notice discomfort in the fingers. Pain is observed with hypertrophic osteoarthropathy.

As stated above, "drumsticks" appear on both the top and lower limbs simultaneously, but in some cases an isolated change can be observed (only on the arms or legs). This happens if the patient has cyanotic forms birth defect hearts. In this case, oxygen-poor blood enters either the upper or the bottom part bodies. Reasons for changes may include:

a) open ductus arteriosus With pulmonary hypertension. In this case, the reverse discharge of blood is accompanied by cyanosis of the feet, but cyanosis of the hands is absent.

b) exit of the aorta/pulmonary artery from the right ventricle. The latter often results in combination with with a defect interventricular septum, patent ductus arteriosus and pulmonary hypertension. In this case, oxygenated blood enters the pulmonary artery, is shunted through the patent ductus arteriosus into the descending aorta and brachiocephalic vessels, entering the upper limbs. As a result, the fingers become cyanotic and deformed, while the feet remain intact.

But there are situations when "drumsticks" appear on one side only. The reasons for this are as follows:

– aortic aneurysm

– aneurysm of the subclavian arteries

– Pancoast tumor

– lymphangitis

– placement of an arteriovenous fistula for hemodialysis.

An increase in the convexity of the nails is a separate symptom that may not be associated with drumsticks. He can talk about more often than the latter chronic diseases that weaken a person (lung cancer, pulmonary tuberculosis, rheumatoid arthritis). Nail transformation develops much more slowly than drumsticks. The change in the nail fold begins 1 month after the onset of the factor and ends approximately 6 months later. During this time, a new nail is formed with deformation like a watch glass.

Diagnostic criteria for finger deformities of the “drumstick” type.

Diagnosis, as was said, is carried out not by increasing the convexity of the nails, but by:

1) Disappearance of the subungual angle of Lovibond. This is the angle between the base of the nail and the surrounding skin. Normally it is less than 180 gr. If “drumsticks” develop, this angle either disappears or becomes larger than the indicated figure.

The disappearance of the angle can be clearly demonstrated by applying a pencil to the nail. Normally, a gap is clearly visible between the nail and the pencil. With “drumsticks” this gap will not exist and the pencil will adhere tightly to the nail. See Figure 1.

Another test is the Shamroth sign. With “drumsticks”, diamond-shaped

The gap disappears. Figure 3. Normally, when the distal phalanges of paired fingers join, there is a diamond-shaped gap between them.

2) The ability of the nail to run. As a result of increased looseness of the soft tissues at the base of the nail, the nail plate acquires increased elasticity upon palpation. If you press on the skin above the nail, it will sink into the soft tissue and move closer to the bone. When the skin is released, the nail springs back and out. This is what voting is.

This can be clearly demonstrated as follows. Click index finger on the skin of the left middle finger just above the nail. If there are no changes, the nail plate will feel like a dense structure connected to the bone. Now pull back the free edge of the nail of your middle finger thumb left hand and repeat pressing. In this case, the nail plate that has moved away from the bone will sink when pressed down, and after the pressure stops, it will straighten, as if the nail is on an elastic cushion.

Balloting may normally be found in older people.

3) Pathological ratio of the thickness of the phalanx. This is an increase in the thickness ratio distal phalanx in the cuticle area (TDF) and thickness interphalangeal joint(TMS). Normally, this ratio (TDP/TMS) is approximately 0.895. If we are dealing with “drumsticks”, then this ratio increases to 1.0 or more.
This ratio is a highly specific and sensitive indicator of “drumsticks”. Figure 2.

Type of terminal phalanx depending on where it predominantly grows connective tissue, may be different. Depending on this name, there may be several options for “drumsticks”:

– “parrot’s beak” – the proximal part of the distal phalanx grows predominantly.

– “watch glasses” – tissue grows at the base of the nail.

– “true drumsticks” – the phalanx increases along the entire circumference.

"Watch glasses"


We mentioned above that the deformation of the nail bed when “watch glasses” appear takes a fairly long time to form. As for the “drumsticks”, changes are happening very quickly. For example, when lung abscess disappearance of the angle and protrusion of the nail bed are noted approximately 10 days after aspiration.

“Drumsticks” with periostosis.

This is hypertrophic pulmonary osteoarthropathy - systemic disease soft tissue, joints and bones, which is often associated with tumors chest cavity(lymphomas, bronchogenic cancer, tumor metastases). In this case, “drumsticks” are combined with periosteal proliferation bone tissue, which is especially pronounced in tubular bones. In addition, GOA manifests itself:

– symmetrical arthritis-like changes in one or more joints(ankle, knee, elbow, wrist).

– coarsening of the subcutaneous tissues in the distal parts of the arms and legs, and in some cases on the face.

– neurovascular disorders in the hands and feet(chronic erythema, paresthesia, increased sweating).

GOA can be combined with “clubs” (cystic fibrosis, bronchiectasis, chronic empyema, lung abscess), or may not be combined (fibrosing alveolitis) - here there will be “drumsticks”, but GOA will not. Unlike simple “drum sticks”, diagnosis is carried out using x-ray and scintigraphy.

GOA is accompanied by pronounced pain in the bones at rest and upon palpation. The skin in the pretibial area becomes warm to the touch; may be observed autonomic disorders(paresthesia, fever, sweating), disappearing after surgical or therapeutic treatment.

Diseases accompanied by the appearance of “drumsticks”

Diseases of the lungs and mediastinum Cardiovascular diseases
Bronchogenic cancer* Congenital heart defects accompanied by cyanosis (“blue” defects)
Metastatic lung cancer* Subacute bacterial endocarditis
Mesothelioma* Infection of coronary artery bypass graft*
Bronchiectasis* Diseases of the liver and gastrointestinal tract:
Lung abscess Cirrhosis*
Empyema Inflammatory bowel diseases
Cystic fibrosis Cancer of the esophagus or colon
Fibrosing alveolitis
Pneumoconiosis
Arteriovenous malformations

* – usually combined with GOA.

Watch glass symptom (Hippocrates nail)- characteristic deformation of the nail plates in the form of watch glasses with flask-shaped thickening of the terminal phalanges of the fingers and toes in chronic diseases of the heart, lungs, and liver. In this case, the angle between the posterior nail fold and the nail plate, when viewed from the side, exceeds 180°. The tissue between the nail and the underlying bone becomes spongy, so that when you press on the base of the nail, you feel the nail plate move. In a patient with the watch glass symptom, when the nails of opposite hands are placed together, the gap between them disappears (Shamroth's symptom).

This symptom was apparently first described by Hippocrates, which explains one of the names for the watch glass symptom, Hippocrates' fingernail.

Clinical significance

When this symptom appears, a complete and thorough examination of the patient is necessary to determine the cause of its occurrence.

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Literature

  • Strutynsky A.V., Baranov A.P., Roitberg G.E., Gaponenkov Yu.P. Fundamentals of semiotics of diseases of internal organs. - M.: MEDpress-inform, 2004. - P. 66-67. - ISBN 5-98322-012-8.
  • Trakhtenberg A. Kh., Chissov V. I. Clinical oncopulmonology. - M.: GEOTAR MEDICINE, 2000. - P. 109. - ISBN 5-9231-0017-7.
  • Chernorutsky M.V. Diagnosis of internal diseases. - Fourth edition, revised and expanded. - L.: MEDGIZ, 1954. - P. 279. - 50,000 copies.

See also

Excerpt characterizing the Symptom of watch glasses

- Well, now the recitation! - said Speransky, leaving the office. - Amazing talent! - he turned to Prince Andrei. Magnitsky immediately struck a pose and began to speak French humorous poems that he had composed for some famous people in St. Petersburg, and was interrupted several times by applause. Prince Andrei, at the end of the poems, approached Speransky, saying goodbye to him.
-Where are you going so early? - said Speransky.
- I promised for the evening...
They were silent. Prince Andrei looked closely into those mirrored, impenetrable eyes and it became funny to him how he could expect anything from Speransky and from all his activities associated with him, and how he could attribute importance to what Speransky did. This neat, cheerless laughter did not stop ringing in the ears of Prince Andrei for a long time after he left Speransky.
Returning home, Prince Andrei began to remember his life in St. Petersburg during these four months, as if it were something new. He recalled his efforts, searches, the history of his draft military regulations, which were taken into account and about which they tried to keep silent only because other work, very bad, had already been done and presented to the sovereign; remembered the meetings of the committee of which Berg was a member; I remembered how in these meetings everything related to the form and process of the committee meetings was carefully and lengthily discussed, and how carefully and briefly everything related to the essence of the matter was discussed. He remembered his legislative work, how he anxiously translated articles from the Roman and French codes into Russian, and he felt ashamed of himself. Then he vividly imagined Bogucharovo, his activities in the village, his trip to Ryazan, he remembered the peasants, Drona the headman, and attaching to them the rights of persons, which he distributed in paragraphs, it became surprising to him how he could engage in such idle work for so long.

The next day, Prince Andrei went on visits to some houses where he had not yet been, including the Rostovs, with whom he renewed his acquaintance at the last ball. In addition to the laws of courtesy, according to which he needed to be with the Rostovs, Prince Andrei wanted to see at home this special, lively girl, who left him with a pleasant memory.