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


42 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 :)

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    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?

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    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.

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  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?

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    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.

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    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.

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  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!

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

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

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

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  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

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    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.

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  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.

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    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.

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  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.

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    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).

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    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.

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    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"

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    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.

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    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.

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  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?

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    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.

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  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..

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    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.

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  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! :)

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    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.

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    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?

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    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.

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  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

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    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.

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    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?

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    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.

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  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.

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    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.

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