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


  1. 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….

  2. 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.

  3. 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

  4. 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

  5. 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?

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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 🙂

  11. 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.

  12. 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.

  13. I am a 46 year old woman. I have this problem in my right hand, (finger next to pinky) never caused me any problems, but sure does look funny and creates a lot of conversations,and laughter. 😁

  14. Dear doctor, my daughter is 9 month old. Recently, When I touch her hand, I feel a bump on the fourth finger joint and when she make a fist, I can feel the knuckle is sink a bit. As she is so young, is there a way to “fix” it? We adore her so much. Thank you!

  15. Melissa,
    Thank you for the question. It is difficult to help without knowing more. I would recommend that you see a pediatric orthopedic surgeon or a hand surgeon (or, if available, someone like me who specializes in kids' hands). Xrays and an examination will help understand what exactly is going on with her hand and lead to the best advice. Sorry I could not be of more help!

  16. Melissa im missing 3 knuckles they are there just pushed back towards wrist..stop worrying be happy you have a healthy daughter..im 42 now and i play guitar and do jiujitsu..my hand writing is not as nice due to the way my hand curls but nobody writes anymore anyway..lol…there is nothing to fix on your daughter go give her a hug 😉

  17. Thanks doctor for your reply! I took her to see an paediatric orthopedist. By observing and touching her hand, he said it is a ganglion and doesn’t need any treatment if it isn't bothering the baby. We are quiet released. Thanks very much for your suggestion!

  18. Hi, I have a shortened 5th metacarpal on my left hand, and only recently noticed. While it has not caused any pain, I have come to realize that when I make a fist, the finger has very limited movement, only to bend forward and straighten out, while the 5th finger on my right hand can move in circles without issue. Is this normal considering I am missing an entire knuckle? Thank you.

  19. Thanks for question. This is a bit hard to answer but yes, there can be associated decreased motion with a short metacarpal. But your experience of no pain is important for other readers. That has been experience in taking care of patients like you.

  20. I have short 4th finger syndrome. But l have pain on 3rd finger. Doctor said its because of short 4th finger and he offer surgery. Is it possible to have pain for another fingers because of short 4th finger syndrome?

  21. While I have not seen significant pain in the next digits, it is possible based the tendon connections and inter- relations of the fingers. BUT, I do agree that this is not especially common. I am also not sure what surgery was offered…

  22. I wish I could offer my experience in this situation. I just have never had a patient in this situation and I have not lengthened a short metacarpal with the expectation of pain being improved in another finger. Another opinion might make sense.

  23. Hi Doc I'm a 30 years old female. noticed I have no right 4th finger knuckle when i was 11. Recently I feel pain and numbness on my index and middle fingers, otherwise I'm okay. No similar thing among my families excpet type 2 DM and recently my elder sister diagnosed with Hypothyroidism. I've nver seen a doctor before. Nver been bothered before hut now I'm getting curious
    I'm glad there's this chatting platform

  24. Hello. Thank you for writing. I am not certain your current symptoms of pain and numbness are related to the short fourth metacarpal. First, there may be other things going on in your hand aside from the short metacarpal. And second, there may be something else going on. An evaluation by an experienced hand surgeon will be helpful. Good luck.

  25. Hi!
    I have this on both hands, the short 4th metacarpal and knuckle set back/looks like it's missing. I was told growing up it wasn't a big deal and shouldn't be an issue/cause pain. I am noticing as i age though, that it is getting increasingly painful in my right hand. I do a lot with that hand – I am an artist and always working with it. It causes pain in that hand, and I am also unable to move that finger without using my 3rd finger as well, it won't move independently. I feel like it throws off the way my hand moves and functions. Is there anything I can do about this? I am now 28 years old. Thanks.

  26. Thank you for sharing your experience. Pain is not common, at least in the patients that I have seen. I would definitely recommend an evaluation by a hand surgeon, ideally one who has experience with kids and adults. Good luck.

  27. Oh my God I am so happy to come across this today.I have the same problem on both hand I have 2 short knuckle and 2 short finger just like the pictures. I have never realized it until I was 11 years old .I always wanted to be a Fashion model but because of my finger that Destroyed my dreams . sometimes I do feel some type of discomfort but It's all depends on what I'm doing . Now I have become a mother the day I gave birth looked at my daughter's finger everything was OK ..6 years later a family member looked at her fingers in realize that she has a short knuckle But only on her right hand …Surgery is definitely an option because I do not want her to go through what I went through ….How do I find a doctor that is specialized it fixing it….I live in New Jersey and I've been looking please help

  28. I have this in both hands and feet. Im 23 and its been my entire life. Is there any option for adults to get it fixed? I want it fixed for my wedding someday. My mom and i were also wondering how rare it is that its all four fourth digits.

    Im so happy i found this. Its been one of my biggest things since i was little.

  29. I lack a knuckle in both my ring fingers. And it's so embarrassing honestly. I would rather go with having the surgery and dealing with the pain. I wish my hands were just normal. It bugs when people stare at them to. I would honestly wanna know how much the surgery is to lengthen both ring fingers..

  30. My sister has both hands shorter 4th and 5th. My other sister doesn’t have this but her daughter does. Same 4th and 5th in both hands. Our mother has a shorter 4th and 5th toes in both feet. My daughter is pretty much missing all of her knuckles. Never noticed until she turned 10!!

  31. Sid, thank you for the comment. It seems as though this is clearly genetic in your family (vs. related to an endocrine abnormality or a random event). OMIM.org is a wonderful site to work through this presentation if it is of interest.

  32. My 9 years old daughter has no knuckles and short metacarpals on both her ring fingers. No issues observed other than cosmetic. No one in my family or my husband's family have this issue. Uneventful pregnancy, unclear to me what is causing this. Kids at her school have noticed the absence of knuckles and short fingers and some have made fun of her. Not sure what to do.

  33. Thank you for writing. This is a typical situation without family history and without functional issue. The deformity may gets worse as your daughter continues to grow. I would provide support for your daughter regarding kids at school and emphasis that this makes her different but does not limit her. Talk about it as she is willing. Surgery can be done to lengthen the short bones but it has risks and certainly creates scarring. Surgery can be considered but it is not my first choice in this type of situation. I hope this helps.

  34. Thank you so much for your answer. Do you know is this type of surgery is done in Canada? If so, could you please share with me the name of a hospital or surgeon so I can explore the options?
    Thank you.

  35. This genetic abnormality runs in my family. I have a short 4th metacarpal on both hands and one foot. I have a sister with short 4th metacarpal on one hand and a sister with it on one foot. My father was missing knuckles on his 3rd, 4th and 5th on both hands and 4th on both feet. We come from a big family on my father's side and all his siblings and their children have some form of this genetic abnormality. During family reunions everybody compares their hands and feet and laugh. It has caused no functional probles with anyone that I am aware of. The trait seems to be disappearing with our children and thier children.

  36. I have lived 44years with missing 4th metacarpals and I play guitar and powerlift..it does not interfere with life other than you will get a callous
    Further down your palm since the knuckle is just set back.
    My whole mother's side has this trait and my sister.
    They were from Germany and Czech republic and 1st generation in this country (USA)…I wonder what
    nationalities everyone else is..anyone else German and slovak origin?
    My sister and I are generation X.
    How about you all?

  37. Dr. Goldfarb, I don't know if this sounds stupid but when I was younger, 10-12-years old, I had a habit of stretching/cracking all my fingers except for the 4th fingers (both hands). Could this have caused a trauma to my fingers and it caused them to stop growing? Whenever you're reading this, thank you, have a nice day and stay safe!

  38. Federica,
    Thank you for the question. I believe that no question is 'stupid'. BUT, you did not cause this and could not have prevented this from happening., There is a genetic piece to this. Good luck and you stay safe also!

  39. Oh my god..I feel so relief after reading this blog and comments..I used to feel like,it was just me but why me.Sometimes this shit hits me with bad trauma,I too want beautiful fingers and nails like other girls.
    Anyway, sometimes I feel different and it's just ok😊

  40. Wow! It is nice to know that I am not alone! I have a shortened 4th metacarpal and shortened 4th metatarsal, both on the left side, plus a shorter, fatter thumb on the left hand. My mother has the one shorter thumb and her mother had two shorter thumbs but I'm the only one with the shorter finger and toe. I also was born with a cleft lip and my nostrils are different sizes. As a child, I found this all embarrassing but as an adult, I make a point to show people my differences. I would rather tell people than have them wonder about it. I certainly embrace my differences and feel that it gives me a little bit of an advantage with my work. I work with people who have Autism and other developmental disabilities and I feel that my differences help me to be more understanding of their differences. We are "different, not less."

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