Pediatric OSCE Clinical skills - Hand signs

This is a non-exhaustive list of some clinical signs helpful for pediatric clinical examination and OSCE station. The elicitation or identification of clinical signs is an important part of OSCE examination as well. This post focuses on clinical signs related to hands, palms, and nails.

Clinical signs of Nail - Clubbing

angle of clubbing
Fig.1 - showing the change of nail bed angle in clubbing .

Clubbing is a characteristic bulging of the distal finger and nail bed.


How to measure finger clubbing

how to measure finger clubbing in children
Fig.2 - showing different interphalangeal depth.

The ratio of the anteroposterior diameter of a fingernail to that at the distal inter-phalangeal joint is a simple measure for diagnosing clubbing. This can be obtained by clippers.

If the ratio is more than one - clubbing is present.

Schamroth Sign

schamroth sign in clubbing
Fig.3 - Schamroth sign in clubbed fingers.

Schamroth sign is used for detecting any evidence of clubbing in the child. Asked the child or help him to place the nails of the right and left index fingers against each other. 

Normally a diamond-shaped gap is seen between the margin of the nails. In an infant or a child with clubbing, this gap is not visible for the obvious reason as the nail beds are full.

Stages of clubbing are

  1. Softening of the nail bed, causing a spongy feeling when the nail is pressed
  2. Loss of the normal < 165° angle between nail bed and fold
  3. Convex nail growth
  4. Thickening of the distal part of the finger
  5. Shine and striation of the nail and skin

Mechanism of clubbing

  1. Normal pulmonary circulation disruption
  2. Megakaryocytes not broken into fragments
  3. Platelet growth factors released
  4. The proliferation of muscle cells and fibroblasts
  5. Clubbing

Causes

Neoplastic

  1. Bronchogenic carcinoma
  2. Lymphoma
  3. Pleural tumors

Pulmonary
  1. Cystic fibrosis
  2. Asbestosis
  3. Pulmonary fibrosis
  4. Sarcoidosis
  5. Hypertrophic pulmonary osteoarthropathy (HPOA)

Cardiac

  1. Cyanotic heart disease
  2. Endocarditis

Gastro-intestinal
  1. Inflammatory bowel disease
  2. Liver disease
  3. Coeliac disease

Infection

  1. Tuberculosis
  2. Infective endocarditis
  3. HIV

Endocrinology

  1. Thyroid disease

Value

  1. Clubbing is always pathological
  2. Absence does not exclude underlying disease

Other Clinical signs of nail

pediatric clinical sign of nail
Fig.4 - List of clinical signs observed in nails. See text below for diagnosis.
  1. Absent part of Nail - Anonychia congenital
  2. Pitting nails - Psoriasis
  3. Cutic Jeinvasion - Lichen planus
  4. Dark brown pigmentation, ridging - Monilia
  5. Dista Onycholysis - Tinea
  6. Spoon nails - Iron deficiency
  7. Discolored nails with an inverted edge - Ectodermal dysplasia
  8. Clubbing in - toxins, malignancy and hypoxia
  9. Short and overcut nails ( bitten) - anxiety
  10. Splinter hemorrhage - Infective endocarditis.
  11. yellow nail- Lymphoedema, Bronchiectasis, lymphoma
  12. Half and half appearance - Hepatic cirrhosis
  13. Ridging - Rheumatoid arthritis
  14. Longitudinal brown Lines - Addison's disease, Breast cancer, Melanoma
  15. White or pale nails - Anemia
  16. Red nail – polycythemia, Systemic lupus
  17. Horizontal white and pink bands - Nephrotic syndrome
  18. Brittle Nail - Hypothyroidism

Clinical signs of palm

pediatric clinical sign in palm
Fig.5 - List of clinical signs to be observed in the palm. See text below for diagnosis.
  1. Anemia - Pale or light-colored palm
  2. Raynaud's phenomenon - Bluish palm especially in peripheries
  3. Hepatitis / Jaundice- Yellow tinge to palm
  4. Addison disease - Darkly pigmented creases over the palm can be seen
  5. Hypothyroidism - Orange palm
  6. Portal hypertension - Palmar erythema
  7. Thyrotoxicosis - Hot and Sweaty
  8. Down Syndrome - Transverse palmar crease
  9. Lung cancer - Tripe (velvety rugose thickening)
  10. Bladder Cancer - Palmar keratosis (papules or pits)
  11. Ovarian cancer Palmar fascial thickening with lumpy areas
  12. Dupuytren's Disease - Palm thickening and pink fingers bend forward
  13. Psoriasis - Thick-red-scaly palm
  14. Kindler Syndrome - Thick glaze palm with decreased palmar creases
  15. Rheumatoid arthritis - Wrist and fingers deformities
  16. Ulnar nerve injury - Clawing of the ring and little fingers
  17. Median nerve injury - Adduction and hyperextension of thumb and index

More on Clinical OSCE 

  1. OSCE - Clinical Procedures
  2. OSCE - Observed station tips
  3. OSCE types - What is a focused clinical examination?
auhtor

About Author

Ajay Agade | DNB FNB Fellowship in Pediatric pulmonology

Ajay is a Paediatric Intensivist, currently working in Pediatric Respirology & LTV at Great Ormond Street Hospital NHS, London