Rare Conditions

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

144 Comments

  1. I have this condition on my right hand the fingers affected is the one between the middle and pinky ring finger I had it for as long as could remember i am 50 years old now never hurts or gave me any problems it just look different because it is shorter and missing a knuckle my left foot my third toe is shorter and is also missing the knuckle had it for as long as I can remember never hurts or gave me any problems I guess it's normal for me I am happy to have found this page and to read all the post and I am not the only one with this condition I was very curious about my toe and finger all my life never met another person with this condition now I know a little about it thank for sharing

  2. I have short metacarpals on my left little finger and my right 4th finger. I noticed when I was 9 and it became more apparent as I grew.
    If you have this, don't be embarrassed! 'Normal' hands are boring. I quite like how my knuckles look and feel weird. I can play piano, cello and bass guitar, and I have no problems with grip when I do things like rowing or rock-climbing.

    The only time it ever annoys me is when playing notes with the little finger on bass guitar, because I think it makes it a bit more awkward to reach and hold the thick strings down strongly enough. Practising with just this finger will probably help though 🙂
    I am female, is it more common in women?

  3. Thank you for sharing your experience! While the short metacarpals are very rare, they can be associated with even more rare syndromes. They are, at least in my experience, more common in women but I am unable to provide exact %.

  4. I am 25 yr old and I have this condition on my both the hands, both the metatarsals of 4 and 5 finger are short..being a dentist at times it hurts to hold forceps for a longer time span or it hurts when I have to apply the pressure…and it's very difficult for me to strum the guitar too… could you suggest something would be great…

  5. Thank you for the question. While it is difficult to give 'blind' advice, therapy might be a good place to start to strengthen the intrinsic muscles of the hand. I doubt there is a surgery that would help. Seeing a hand surgeon with experience in this area would be the best next step. Feel free to email me directly if help: congenitalhand@wustl.edu

  6. Hi i have this in my both hands and feet. I have extra fat on both hand fingers which makes it obvious. Just like this patient's finger. Would you recommend a small procedure to cut the extra fat on 4th finger. Since the bone lengthening is risky i don't wan't to take that risk with my hand.
    p.s. Thank You for this Blog 🙂

  7. I have the wide thumbs on both my hands.. my 4th finger on both hands are very short but I do have both knuckles but they sit far back.. I would like to learn more about this. I am 37 and healthy and I havent seen anyone genetically in my family with this.. I did learn I had an unknown maternal grandfather and so I just dont know… I wanna learn more.

  8. Hello my daughter (8) has short metacarpals on 2345 on left hand and 345 on right hand, so basically only her right index finger metacarpal is normal and outgrowing the rest. Are you aware of any procedure that can shorten or slow the growth of the normal metacarpal?

  9. Raffi- thank you for the question. That is an unusual presentation of short fingers. However, your question is a good one. Yes- we can slow down growth of individual bones. It will be important to see a pediatric hand surgeon who can calculate growth remaining and determine the best time to stop bone growth. This can be a highly effective surgery. Good luck.

  10. Dr. Goldfarb,

    I am a 28 year old healthy male with bilateral short 4th mets. My mother and sister also has short 4th mets. My labs are all normal. My wife is also healthy and has bilateral short 4th and 5th mets with normal labs. She was recently screened for the GNAS gene, which was normal.

    We are concerned about passing down this defect (or associated defects such as mental impairments.) I was wondering if you've seen this in your experience and what your recommendation might be.

    Best,

  11. Thank you for writing. You are correct- in all likelihood, there is a genetic predisposition to your short 4th metacarpals. If you search at OMIM.org, there are lots of potential genetic conditions (obviously the vast majority do not apply). The GNAS gene is a thought. The other possibility is an endocrine abnormality but less likely given how common in the family. Good luck. A geneticist might help.

  12. Hello Dr Goldfarb,

    I am a 28 year old woman , I also have a short 4th metacarpal , I’m missing my ring finger knuckle, I lived with this all my life with no pain, but recently I started getting shooting pains from the affected finger up to my elbow , I wanted to know what could possibly cause this

  13. Hello Melissa,
    Thank you for the question. Typically, the short fourth metacarpal does not cause pains as you describe. There are other possible causes of radiating pain including nerve issues. I would check in with a hand surgeon for an assessment. Good luck.

  14. Hello I just stumbled across this article while trying to learn a little bit more about this. I have this on both hands, as well as my mother, brother, uncle, and past grandfather.

  15. I am 76 years old and have this on both hands. I found out nobody ever noticed it unless I told and showed them. Never any problems.

  16. I'm 78 and was just given the name of this. I have the short metacarpal only on my 4th finger on my left hand and felt self-conscious when I was a teen and young adult, especially wearing wedding rings (Rings do emphasize the extra "fleshiness" of that finger). But I learned most people don't even notice it. I've never met anyone else with it, but never had any pain or problem other than a little more difficulty/stretch playing the piano and viola. None of our 4 children have it and so far it hasn't shown in our 12 grandchildren. The only possible associated endocrine condition in the family which I share is hypothyroidism.

  17. Hello, I came across this article recently after looking into possible reasons for my 8 yr old daughter's 4th finger being shortened and thinner towards the tip on one of her hands. Her fingernails also seem to show some abnormalities by appearing round and shortened on both of her hands. As she has gotten older the size of her ring finger has definitely become more pronounced on the one hand, and is showing a noticeable difference in size. When she was younger her doctors thought that her hands were showing some abnormal characteristics possibly associated with the same unknown condition as her feet, but were unsure and xrays didn't show anything abnormal in her hands. Although, it has been a few years since xrays we're taken of her hands. She does have a congenital condition that affects her feet, where she is missing several toenails, and has missing or underdeveloped distal and middle phalenges. Most of her toes are affected to some degree, but some more then others, especially the middle and big toes. We have seen geneticists, and she is a patient at Shiners Children's Hospital in Portland, Or. She has had genetic testing and mapping of her genes with certain genes identified but with unknown significants. The syndromes associated with the genes do not fit her clinical presentation, nor does she fit known syndromes that affect the digits. I'm wondering what syndromes or conditions come to your mind that I could possibly shared with her doctors? Thanks

  18. Thank you for writing. This does not seem to be a simple short metacarpal but rather more similar to symbrachydactyly (although symbrachydactyly usually only affects one extremity). A Shriners Hospital is typically a great place for diagnosis in uncommon conditions but not sure if such a diagnosis has been provided. A genetic diagnosis is great when it can be provided but honestly, this is not commonly possible. An experienced clinician (i.e., busy hand surgeon) will have a good perspective. Good luck.

  19. My 4th and 5th on both hands have been like this for as long as I can remember (33 now), but not as drastically shorter like the pictures above. It's interesting to put a name/reasoning to it! I guess I'm just missing 4 growth plates! Thankfully I've also have never experienced pain, and I've always just told people I have "baby knuckles" lol
    Have never met someone else with the same look to their hands! Thanks for writing this!

  20. This is half a decade late, but I have the exact thing on my left hand. It is a common association with Turner’s Syndrome. I don’t know the etiology behind it but that is what I was told

  21. I also have the same problem with fourth finger in both my hands and feet.I have never seen people with this problem like me and find its very embracing but now I m glad to find this article and people like me:).love from India❤️

  22. I am also and artist and have this in both hands. As well as short forth, I have short fifth on my right hand. This causes me pain as well since I use my hands a lot. I have been to a hand surgeon and he told me there really wasn't much that could be done. He did, however, recommend I wear a brace when it causes me pain. I attended physical therapy for a short period of time but found that it wasn't that helpful. To help with the pain, I just wear a brace when pain flairs up or I wear compression gloves if it is persistent.

    I hope this helps. From one artist to another.

  23. My 33 yr old daughter has shortened 4th metacarpals in both hands, as she has aged, occasionally her hands hurt. When she was about 6 or 7 she came home, clenched both hands and said, look mum!! I was horrified, thinking she was missing both her knuckles, I whizzed her up to the doctors, who referred me to a genetic doctor, upon going through all the known syndroms, she did not fit the rest of the criteria, she was exceptionally tall and skinny, for one.
    On two occasions, years apart, we looked into having the operation to correct the metacarpals but the risk of over stretching the tendons, which would cause her finger to sit in an un natural position, out weighed the benifits. As far as I know, she is the only one in the family with this condition, her younger sister's hands are normal. Both daughters were diagnosed with ADD and the older with dyscalculia, so not necessarily mentally retarded, as with some of the known syndroms.

    Recently, I read an article about peoples abnormalities, there was a picture of someone with the shortened 4th metacarpal, in this section, they said that people with this, have hypermobility. Which has lead me to this article, I have never associated her flexability to the shortened 4th metacarpals. My daughter has hypermobility but does not fit the rest of the criteria of the syndrome that states these people have hypermobility.

    Have you heard of other people or know of people, who have the shortened metacarpals and hypermobility?

    1. I have this in my right pinky finger. I always thought I was just born without a knuckle. I also have lipedema which has hyper mobility as one of its many symptoms. So this just became very interesting. Thank you for this article.

  24. I have a missing knuckle on my right ring finger. It does not cause me issues but my right hand is a little weaker then my left. I do not know how it happened or if I was born with it. I do not know if this has a name or anything. The doctors do not know how I got it nor do my parents. My right ring finger is shorter than the one on my left and when people see it they freak out. Do you know what this is or if it will cause me any issues? Or anything with genetics?

    1. Morgan,

      Thank you for writing. This could very well be genetic (ie, something you were born with) or you could have injured the growth plate in the metacarpal (less likely). Please see links on the page for addition resources. Good luck.

  25. My 12 year old son has no knuckles on the ring finger on both hands. He is very self conscious about it. I am wondering if you recommend any procedure to correct this issue.

    1. Hello and thank you for the question. While difficult to know without X-rays, it may be that a short 4th metacarpal is responsible. There is an option to lengthen the metacarpal as noted in my posts. However, the decision to lengthen the metacarpal is complex and a good discussion with a congenital hand surgeon is recommended. This surgery can be successful but there are also complications with surgery that need to be understood. I hope this helps.

  26. I, too, have a missing left ring finger knuckle. My older sister is missing her right fifth knuckle and younger sister is missing her 4th & 5th knuckles on both hands. Mine is exactly as my Dad’s (missing left ring finger knuckle) and his mother was missing the ring finger knuckle on both hands. I showed this to one of my teachers in school when studying genetics and she said it was a sex-linked genetic trait.

    1. Vicky- thank you for sharing. There are a number of genetic transmission pathways but I would never disagree with your genetics teacher!

  27. I have this on both my ring fingers, I’m in my early teens now and I really appreciate people talking about this. I am still insecure about it and sometimes even check to see if it’s noticeable on photos before posting but these comments are genuinely so amazing. I made the mistake of showing it to my friends but they sometimes tease me about it or show other people in my class, then they ask to see my knuckles all the time which makes me more insecure! My finger length isn’t 100% noticeable yet but I worry that my pinky will grow longer than my ring finger and I’ll feel even worse. (I struggle with mental health and self-confidence)

    Just wanted to thank everyone who commented for being so open and truthful about how cool this condition can be! Thank you all xx

    1. Robyn,

      Thank you for your post. The good news is that given your age (early teens) it is unlikely the metacarpal growth will make this more noticeable.

  28. I’m a 62 year old female and noticed my ring finger was shorter and missing a knuckle when I was around 9. I just got my hand x-rayed for another reason and asked the doctor about this and he said that I was born with it. But I remember a pretty brutal game of knuckles when I was around eight or nine and always thought that that game contributed to it. Could it have been this trauma? Or is it more likely that I was born with it?

    1. Debbie- thanks for writing. I do agree with your doctor- this most likely something that your were born with. If you have kids, it might be interesting to know if they have this?

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