My hand’s a bit munted.

Bloke arrived in ED holding  his “Munted hand!”

Patient was clearly in pain with a deformed hand:


Mechanism of injury was fall from BMX wedging hand between a large rock and tree.


Analgesia and off to x-ray:

metacarpal disolcation 3


Metacarpal dislocation 2

The films show Carpometacarpal dislocations of 3rd 4th and 5th (and possibly 2nd according to radiology) But no associated fractures on any views.

Titrated fentanyl was given for analgesia and midazolam was added for the reduction.
The reduction only required minor force applied to base of metacarpals and longitudinal traction.

Post reduction films showed:

metacarpal dislocation reduced

Patient was taken to theatre later that day for K-wire fixation.

The patient was planning to be back on the bike after removal but couldn’t help himself and was out riding 4 days post cast removal (day 11 post reduction)

So the Munter with the munted hand is doing well. K-wires removed at clinic increasing strength and not too much stiffness. (the benefit of early mobilisation?)

I was going to write more about Carpometacarpal Dislocations but Chris Partyka has covered it so well over at The blunt dissection I thought pointing you there would be better.

The Unofficial Bone Shop House Surgeons Survival Guide

During my time in Christchurch I worked in the bone shop,

There was a book/PDF that was distributed which helped many of us early on and serves as a great refresher.  In the interests of #FOAMed I thought I should share a couple of links.

Before doing this I checked with Chris Cresswell ( @emtutor ) who wrote the original! which has since been edited. Its full of practical advice and worth a read. The word doc is good to have on your smart device of choice. As with all of these sorta things, doesn’t replace your local advice/protocols, If it seems odd check something else!

I decided I should put the first page up so you can get the flavour and practical nature of it.

viva la #FOAMed

  • The Unofficial Bone Shop House Surgeons Survival Guide
  • Welcome to The Bone Shop
  • Don’t try and read the whole of this guide.  Read the introductory paragraphs, then before you see each patient look at the X-rays, read any previous notes, referral, consultant film reading, look the injury up in this guide, talk to the nurse, look up McCrae and decide what you’re going to do before the patient comes in.
  • Everyone expects you to know nothing.  The nurses know everything and will give you lots of help.
  •  For the first few weeks you will feel you are superfluous and are slowing things down.


  • It’s not your fault the waiting room is full: the head of department acknowledges there is a staff shortage and inadequate orientation.
  • What is acceptable angulation/displacement? A lot of the time we don’t know.  If you can get anyone to define “acceptable” for various injuries please add it to this guideline


  • Consider non accidental injuries.  Have a low threshold for discussing with paeds reg.
  • Consider bone strengthening medication for post menopausal women and men over 65 with #s.  We can prescribe calcium (eg calcium carbonate 1.5g bd) and vitamin D (eg calciferol 1.25mg daily for 7 days then once a month).  They need to see their GP to obtain bisphosphonates (eg alendronate).
  • Analgesia/sedation:Bier’s blocks may be performed by an anaesthetic SHO (or above) and are available in “working hours” (d/w duty anaesthetist), or you can do them yourselves provided there are 2 of you – one to do block and manage the cuff – and the other to do the manipulation.  You need to have attended a teaching session on Bier’s block by Anaesthetists prior to being able to perform the blocks yourselves.We do not currently use ketamine/propofol/etomidate in Bone Shop.


  • One alternative is using haematoma blocks (including selected ankles that need manipulating), regional nerve blocks, IV fentanyl eg 100µg, IV midazolam eg 1mg (or 0.5mg in the elderly) and Entonox.
  • For kids consider using 2µg/kg intranasal fentanyl as analgesia.
  • Consider using the 70% nitrous mixer from ED if you’ve been trained to use it. Remember to turn it off.



Text copy on EM tutorials:

Dropbox for word download.





Bit of a yarn

Now for something a little different.

A story from theare. I was assisting with a lap appendix. when a theatre nurse came into theatre and feel the ground laughing.

After a considerable time she was able to calm down enough to tell me this story.

The orthopaedic theatre next door was performing an IM nailing for a extracapsular NOF. Pt had be taken to theatre pretty promptly as was found on floor but no concerns with U+E and space on acute list.

The operation had gone smoothly with the consultant supervising a registrar. Then as the registrar began hammering the nail it stopped. So he hit a little harder. He was then dressed down by the boss for being “a little girl” after which he hit a little harder. Then the consultant took over. after much hammering and swearing a larger hammer was requested, same result. At this time the medical student at the back of the theatre said very meekly “I think this patient might have had her knee replaced”

Pin-drop silence.

Said nurse had to make her speedy exit to our theatre to avoid life threatening orthopedic rage.

Radiology was called for and showed the reason for the nail stopping. The cemented Total Knee replacement… Sometimes even if your only tool is a hammer and you can use it well, its worth checking where the nail is going.