Inherited defects of skull ossification often manifest as symmetric parieta
l foramina (PFM; MIM 168500). We previously identified mutations of MSX2 in
non-syndromic PFM and demonstrated genetic heterogeneity(1). Deletions of
11p11-p12 (proximal 11p deletion syndrome, P11pDS; MIM 601224; ref. 2) are
characterized by multiple exostoses, attributable to haploinsufficiency of
EXT2 (refs. 3,4) and PFM. Here we identify ALX4, which encodes a paired-rel
ated homeodomain transcription factor, as the PFM disease gene in P11pDS.