Sunday, April 5, 2015

The Short 4th Metacarpal

We will, from time to time, evaluate a patient presenting with a painless shortening of the 4th (and sometimes 5th) metacarpal.  Often, the complaint is of an absent knuckle or a different- appearing hand.  Here is one such 14 year old patient.  The primary issue is the shortening of the ring finger metacarpal bone although the pinky does look somewhat short also.

Patient presenting with a short 4th metacarpal.

Patient with a short 4th metacarpal- notice that she lacks a knuckle on the ring finger.

Side to side comparison of short 4th metacarpal patient affected on one side only.

Side to side comparison of short 4th metacarpal patient affected on one side only.

X-rays tell the whole story.  Notice how short the 4th metacarpal is compared to the other metacarpals.  There is no growth plate in the 4th metacarpal.

x-ray showing short 4th metacarpal.

Thankfully, in this patient and others like her, this is a painless problem and one that rarely causes a functional problem.  So, we recommended careful observation and if problems ever do occur, there are options for treatment.  The most reasonable option is to lengthen the 4th metacarpal bone- here is a previous blog post on the topic.  However, the challenge with this procedure is the balance of the tendons.  The patients muscles and tendons have grown accustomed to their current length and if we make the bone longer, the tendons do not always adjust well.  Yet another reason to not intervene unless pain or functional problems are noted.

Finally, we all wonder why this happens.  There are many possible causes.  This site summarizes the possible causes.  
- Trauma.  If the growth plate to the 4th metacarpal was injured when the patient was much younger, it might have shut down and simply not grown any further.  This patient, and most, do not recall such a trauma.
- pseudohypoparathyroidism or pseudopseudohypoparathyroidism.  OMIM describes the second issue very well here.

Finally, here is an article on the topic.

Thanks for reading.

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu


65 comments:

  1. I have this same abnormality on both my hands ... I am 48 years old and it has never been an issue - only a topic of conversation :)

    ReplyDelete
    Replies
    1. Kelzpage,
      Thank you for your comment. Very helpful!

      Delete
  2. I have this on my right hand, could it be passed down as a hereditary genetic defect, or is it a crazy genetic once off?

    ReplyDelete
    Replies
    1. Thank you for the question. Most likely, this is a random event without a known genetic event. However, there are types that are genetically determined including some types of pseudohypoparathyroidism.

      Delete
    2. I am 42 and have on both hands missing 4th..my sister has missing 4tu and 5th as well as my mom its absolutely hereditary and i play guitar and never have had any dexterity issues.
      But this is absolutely passed in my family

      Delete
  3. My 11-year-old daughter has this in both hands and one foot. She is experiencing pain that radiates from her hand to her shoulder. Is this to be expected as she continues to grow?

    ReplyDelete
    Replies
    1. Beth,
      Pain is very unusual in this condition. The short metacarpal may not be the reason for her pain. Hopefully this will resolve on its own but an evaluation by an experience pediatric hand surgeon might make sense.

      Good luck.

      Delete
  4. Hi, I'm happy to have found your blog. I have a short 4th metacarpal on my left hand and on both of my feet in the 4th position. I also have "clubbed thumbs" on both hands and a few bone anomalies in my mouth (bump on roof of mouth and two protruding bones behind my teeth on my lower jaw). Do you think these are all related and may point to any sort of syndrome? Thank you in advance.

    ReplyDelete
    Replies
    1. April, thank you for your question. While I do not immediately recognize a syndrome based on your description of the bony differences you shared, a syndrome is possible. Is there a family history of anything similar? If you visit the OMIM site and type in short 4th metacarpal, you will see some examples of the possible conditions.

      Delete
  5. I was so glad to find this site - I also have this condition and look identical to the patient in the picture (my left hand ring finger is the finger affected). Thanks so much for putting this information out there - most of my primary physicians have not known much about it, and just say 'hmm' when they look at it, so I've always craved more information. Thank you!

    ReplyDelete
    Replies
    1. It is my pleasure. Thanks for sharing your experience!

      Delete
  6. I have this in both hands. I didn't meet anyone else like me until recently. It's nice to find this page.

    ReplyDelete
    Replies
    1. Hailstorm. I am happy the post was helpful. Usually this condition is not painful and treatment is not necessary. Good luck!

      Delete
  7. Hi I have the 4th knuckle missing on both hands which was only notice at the age of 12 , no pain or other symptoms , nevertheless I have sickle cells trait , could that be the cause ? Thanks

    ReplyDelete
    Replies
    1. Jeana,
      Thank you for the question. Your question is a good one. We believe that most cases of the short 4th metacarpal are present from birth but may not become apparent until the period of growth with adolescence. It is possible that sickle cell could play a role but I don't know of any evidence for that theory. It is more likely a genetic issue different from sickle cell trait.

      Thank you.

      Delete
  8. i have this on my right hand and find it very embarrassing to show my hand. i find incidences when i need to show my hand e.g. shaking hands very humiliating as people stare as if I'm a freak. would really like surgery to lengthen.

    ReplyDelete
    Replies
    1. Fatima,
      Thank you for the question. I am sorry you are so concerned about your hand appearance- each patient will have a different opinion on appearance. There are two problem with lengthening the metacarpal: 1) It creates a long scar on top of the hand 2) There is a risk of stiffness of the finger after lengthening.

      I hope that helps. Good luck.

      Delete
  9. What if all our metacarpals are short like that? I was a strength athlete in high school and just always thought my hands were small. They are becuase of this. Both the region in the palm and the fingers themselves are long but the metacarpals are short.

    ReplyDelete
    Replies
    1. Qassem,
      Thank you for the question. This is unusual. The metacarpals make up the palmar length so if the metacarpals are short, typically the palm will seem short also. I hope that makes sense. I do not know of another diagnosis when all the metacarpals are short with normal fingers (phalangeal bones).

      Delete
    2. Is this something I can have fixed? I have normal function in my hands, it's just it is very ineffective for my strength training(past). I got very strong as a highschool student, but still, my hands always help me back. Especially with pulling movements.

      Delete
    3. Unfortunately, I doubt there is a 'fix'. I would recommend an evaluation by a hand surgeon, ideally one who is experience with birth differences. Good luck.

      Delete
  10. I have this same abnormality on my right hand (pinky). My brother has this in on both pinkies. It's so embarrassing. Will I be able to tell if my daughters have this? Or is this something I have to wait until they start growing? I have looked on both of their hands and haven't noticed a "missing knuckle"

    ReplyDelete
    Replies
    1. Tiago,
      You will probably have to wait until your daughters grow a bit before this will make itself know. Thankfully, function will be good!

      Delete
  11. I'm a 46 year old woman who has same abnormality in both hands, 4th metacarpals. My second cousin has it in both feet, 4th metatarcels. My daughter was born with Achondroplasia. None of these things are linked genetically, per a genetic specialist. When I was in middle school, I had them corrected. This was done by Dr Richard Smith at Mass General in 1982 and 1983. I was a clarinet player and had difficulty reaching keys. Both metacarpals were lengthened with cadaver bones and each one secured by two different methods. I wore incredible contraptions to stretch the tendons in my fingers. The right hand had a pin in it, that was removed by pulling it out, not requiring additional surgery. The left one has a plate and screws. Both fingers function beautifully. The right hand doesn't look as good as left hand. But nobody notices the missing knuckle, except me. It's there but just very small in comparison to the left.

    ReplyDelete
    Replies
    1. Amy,

      Thanks for sharing. Dr Smith was one of the great hand surgeons and served as a mentor to many. As you note, this operation is complex with tendon balancing as one of its challenges.

      Delete
  12. Great article! I have the same issue on both hands 4th metacarpal AND both feet in the same area. Both toes next to the pinky toe. I had my toes lengthened though. Any idea why/how both my hands and feet got this abnormality?

    ReplyDelete
    Replies
    1. littlemissnotsoperfect,
      Thank you for the comment and question. There is likely a genetic component to this condition (even if no one in your family has this). Interesting that your toes were lengthened- that is an uncommon surgery.

      Delete
  13. I'm happy that I found this article. I also have a short 4th bone, and have seen a hand specialist once at the age of 12 in Philadelphia. I broke my hand as a child and now at the age of 23 it is causing me severe pain. Especially in the winter.. Wondering if there is a cure for this..

    ReplyDelete
    Replies
    1. Thank you Joanne. Short metacarpals are rarely painful and, therefore, we rarely consider intervention. However, if severely painful without other identifiable causes, lengthening of the bone could be considered. Not a cure but could be helpful. However, lengthening is not straightforward and will not be the best choice for most. Good luck.

      Delete
  14. Hello, I'm 21 and I have this on both ring fingers. I know the surgery isn't recommended, but do you think the extra skin built up can be removed? I am self conscious about the appearance and am getting engaged soon! I don't want to bring attention to my finger with a ring.
    Also, thank you for writing this article! I never knew what my condition was called or if others had it too! :)

    ReplyDelete
    Replies
    1. Hello and thank you. I am not familiar with 'extra skin' associated with this diagnosis. However, if that is the problem, there may be surgery which can help. Find a hand surgeon near you with experience in treating birth conditions of the hand and arm. Good luck!

      Delete
  15. Thanks for this blog. My daughter has a shortened 4th metacarpal on both hands and feet. She is 11 but I am concerned that as she grows the shorter fingers will give her problems. Will they grow still? Also since it is consistent on both hand and feet is it more likely connected to a syndrome? Should I be looking for other possible symptoms.

    ReplyDelete
    Replies
    1. Kim,
      Thank you for your question. As mentioned, the short 4th metacarpal can be associated with several conditions including pseudohypoparathyroidism (or variants) or various syndromes (as well as trauma or infection although these are less likely given that both hands and feet are involved). I would suggest a discussion with your pediatrician and possible endocrine workup. Good luck.

      Delete
  16. Hi I'm 17 years old and also have this on both ring fingers. They are fully functional and no pain but I am embarrassed and uncomfortable, especially when people realize. I really want to get surgery to fix it. Is it possible and safe? Will the knuckles grow into place once the finger is extended?

    ReplyDelete
    Replies
    1. Jimmy, thanks for your question. While surgery is possible, in general, I don't encourage it for people who are functional and have no pain. Your hand will be scarred from the surgery and will still not appear 'normal'. I hope that makes sense and helps. Discussing this with a hand surgeon who treats kids will be helpful for you.

      Delete
  17. Hi! My mother had the issue just on one of her hands, one ring finger, as well as one foot on the 4th toe.
    However, I have the hand issue with both ring fingers, as well as my left middle finger.
    My identical twin has the same situation with her hands, but both of her fourth toes have the issue too.
    There seems to be something genetic about it. Why do you think we are missing more than my mom? And why are my toes normal when my sister's arent??? We are both 22 and it has been bothering us for a while

    ReplyDelete
    Replies
    1. Samantha,
      This seems to be clearly a genetic issue and it is not always the same from person to person or generation to generation. I hope that helps.

      Delete
  18. I have this abnormality on both hands I want to know why and how can I fix it.

    ReplyDelete
    Replies
    1. Darrell,

      Thank you for the question. Hopefully, and usually, this does not need to be corrected. If painful or causing problems, there may be treatment options including lengthening.

      Delete
  19. Hi, I'm 16 Years old and i have a missing knuckle on my ring finger. All my fingers are normal sized and none of them bother me. Both of my parents have knuckles that are present. I have a younger sibling that also has a missing knuckle in the same area. What is the cause of this?

    ReplyDelete
    Replies
    1. Hello Josselyn,

      You may have a short metacarpal. There are numerous reasons but given your sibling's similar situation, a genetic cause is likely. One option is to search on OMIM.org- just type in short 4th metacarpal.

      Delete
  20. I have 4th metacarpal short on my foot, my mother's 5th metacarple on her hand is short/no knuckle with fist (she is only one of 5 siblings with this,her parents don't have it), my first cousin on mom's side has short 4th metacarpal on his hand and my 7 year old son is now showing signs of no knuckle on the 4th metacarpal. None of us have pain or other issues except my mother and I are 4'11" and 5'1" and my son is only 45 inches, wonder if age 7.5 is young enough to get his 4th metacarpal bone growth stimulated with treatment of some kind.

    ReplyDelete
    Replies
    1. Aakatiezz,
      Thank you for sharing your experience. This does sound like an inherited condition- sometimes the website-www.omim.org can be helpful in sorting this out. A geneticist would be helpful and a pediatric endocrinologist might be helpful as well. Finally, I am not convinced that a congenital hand surgeon will recommend surgery, it would certainly be a good place to seek advice.
      Good luck.

      Delete
  21. My 13 yr old daughter has the 4th metacarpal on her left hand. She was about 9 or 10 when we noticed it. As she has gotten older she has lost the strength in her hand and experiences pain, she has problems holding some things and has difficulty opening bottles and similar things. Is there anything that can be done to help.

    ReplyDelete
    Replies
    1. Toni,
      Thank you for the question and I am sorry you daughter is having pain and decreased strength. On occasion, there may be therapy which can help (and this is always a good first step) and on rare occasion, surgery to lengthen the metacarpal might make sense. I hope this is helpful.

      Delete
  22. I have the same problem and wondering if I have a daughter she will have same problem like me or not ?

    ReplyDelete
    Replies
    1. Yasemin. I assume that you are the only member of your family with the short metacarpal. If so, then it is uncertain if you children will share this hand difference. Sorry I cannot be more definitive.

      Delete
  23. I'm a 40-year-old female, and I have a shortened 4th metacarpal and shortened 4th metatarsal, both on the left side, discovered when I was around 10. My first son was born with bilateral polydactyly, with the "accessory digits" attached on the sides of his pinky fingers. I've always wondered if my condition and my son's could be related. Do you know of any research linking the two?
    Kindest Regards,
    Kim Lane

    ReplyDelete
    Replies
    1. Kim,
      Thank you for the question. I certainly have seen various situations in which a parent and child have different hand anomalies although polydactyly and shortened metacarpal/ metatarsal are tough to connect. I do not know of pertinent research- sorry.

      Delete
  24. My wife has fourth knuckle missing and it doesnt hurt her or do anything. Her fingure can move absolutely fine. No one in her family has got this disorder and she is the only one. Can this issue be passed on to my kids or its a one off disorder? Please advise. Thanks

    ReplyDelete
    Replies
    1. John,

      Thank you for the question. I am glad your wife is doing well. That is the experience of most people with a short metacarpal. It is unlikely to be passed on but there is a small chance that this is genetic. I hope this helps.

      Delete
  25. I play the piano and I wouldn't want to ever stop. I have 2 missing knuckles on my left hand and that sometimes causes minor pain whenever I play. Is it possible I can get surgery to lengthen then and help me with my performance? Im 16 and im glad I'm not the only one that has this....

    ReplyDelete
    Replies
    1. Thanks Eva. I am glad you are playing the piano and shouldn't stop. I don't think the missing knuckles will limit you aside from, as you describe, occasional mild pain. Surgery to lengthen the knuckles rarely makes sense but could be an option in patients with pain which limits function. I hope that makes sense.

      Delete
  26. My daughter has had this on both rings fingers. We just noticed it about a year ago. They are now sending us to a endocrinology clinic cause she is now 13 and has high hormone levels for 2 years. She still hasn't started her period yet. They are pointing more to hormones maybe the reason why. Has anyone else heard of this? Also her pediatrician said it could be caused from scarlatina. My child never had scarlet fever so this was odd to hear. I'm looking for answers for this cause I heard it can cause her organs to possibly not grow either on the inside. So I'm freaking out.
    One worried mother

    ReplyDelete
    Replies
    1. Thank you for writing. It seems as though an endocrine visit makes sense. Generally, we do not identify a hormonal explanation for short metacarpals although this is considered one cause. Good luck!

      Delete
  27. Hello, My mother has short 4th Metacarpals on both hands and i have a short 4th metacarpal on my right hand and a short 5th metacarpal on my letf... We are the only people in our family with short Metacarpals... Could it be possible that my mother has started a genetic trait that will carry on to further generation?

    ReplyDelete
    Replies
    1. Catelyn,
      Thank you for the question. It is possible that there is a genetic trait that may be passed on. It is also possible that your mother's mom or dad may have had a milder deformity. There are no easy diagnostic tests to my knowledge at this point.

      Delete
  28. I have this in all fourth fingers and toes (although left foot is hard to discern). I am 58 years old and have experienced many broken fingers playing ball games, but they have never caused me any pain. To be honest, the biggest issues are shoes (sandals), carrying bags (straps cut in) and wearing jewelry. I also find the excessive tissue on my hands a little unsightly (my issue really). I have toyed many times with corrective surgery, but they all work and the outcome of surgery might be less effective hands. It's nice to think this may be an aberration as none of my children have it and I was concerned about passing it on.

    ReplyDelete
    Replies
    1. Rene- thank you for sharing your experience.

      Delete
  29. I have this it is associated to Turner syndrome doctors have told me that there is nothing they can do but I want to know your opinion.

    ReplyDelete
    Replies
    1. Lili lil,
      Thank you for your question. A short fourth metacarpal bone in the hand is associated with Turner Syndrome. We usually recommend watching this as it is not painful. The bone can be lengthened but the surgical scars are usually pretty prominent. I hope this helps.

      Delete
  30. Hi, I am a 28 old female with short 3rd and 4th metacarpal bone in my left hand and a 4th one in my right hand. Somehow I could ignore the fact that it may be genetically passed through generations until this day but now I kinda feel that it is in fact very likely to be genetic (now I started to think about my mom's different 4th fingers in her both feet). Looking at my sisters and my other cousins normal fingers and bones I assume that it is not severe anyhow in my family but I can't help but asking if I'll have a child how would it be?

    Anyways, I was searching about the reasons behind it and I found out about Turner Syndrome. Can I learn if I am missing a chromosome by asking for a chromosome analysis or something like that? Because by looking at that syndrome I might not even have a child :)

    Am I getting paranoid or all the maternal diseases that we got in our close family (like hashimoto thyroiditis of my aunt and her child and bone malformation in my own family) can be related with the same genes?

    Lots of questions in my mind... But I want to state that besides its physical effects it has a huge impact on personal development and psychology. I am now fine but I wasn't very self-confident when I was younger. I hope there are good research papers on this side of this anomaly.

    After all thanks for this blog, it enlightened me :)
    Regards,
    Mel

    ReplyDelete
    Replies
    1. Mel,
      Thank you for the comments and question. You should seek out a geneticist for advice on conditions and potential testing. The genetics doctor will be a good source of information about yourself and potential children. It is doubtful that other familial diseases are related to the short metacarpal. Good luck.

      Delete
  31. i just found this cite.Im from Nairobi Kenya and i have never seen someone with missing 4th finger knucles untill i saw this thread.im glad im not the only one with this condition.My fourth 4th toes also dont have the knuckles and are shorter than normal.my only problem is showing people my “interesting embarassment”as both hands and toes function properly.They are neighter painful nor causes hand and toes discomforts.I have learnt to embrase my missing knucles fingers and toes.For those looking for away to correct them , Wishing you all the best.Thank you so much for this article.

    ReplyDelete