ATLS Musculoskeletal Trauma 2 — Questions and Answers
Question 1: A patient presents with a deformed, swollen thigh after a motorcycle collision. Distal pulses are weak. What is the most important initial step?
- Obtain X-rays before intervention
- Apply traction splinting and reassess neurovascular status (Correct answer)
- Prepare for immediate surgical fixation
- Apply ice and elevate
Correct answer: Apply traction splinting and reassess neurovascular status
Femoral shaft fractures should be managed with traction splinting to reduce pain, control hemorrhage, and restore alignment.
Femur fractures can result in 1-1.5 liters of blood loss. Traction splinting restores femoral length, reducing thigh volume and providing tamponade. After splinting, reassess distal neurovascular status.
Question 2: Which fracture is most commonly associated with life-threatening hemorrhage?
- Distal radius fracture
- Tibial shaft fracture
- Pelvic ring disruption (Correct answer)
- Humeral shaft fracture
Correct answer: Pelvic ring disruption
Pelvic ring disruptions can cause massive hemorrhage from the presacral venous plexus and internal iliac artery branches.
Estimated blood loss: pelvis 1500-5000+ mL, femur 1000-1500 mL, tibia 500-1000 mL. Pelvic fracture mortality for hemodynamically unstable patients reaches 40-60%.
Question 3: A patient with a tibial fracture develops severe pain disproportionate to injury, pain with passive toe extension, and a tense compartment. What is the diagnosis and treatment?
- Deep vein thrombosis; anticoagulation
- Acute compartment syndrome; emergent fasciotomy (Correct answer)
- Fat embolism syndrome; supportive care
- Fracture malreduction; re-splint
Correct answer: Acute compartment syndrome; emergent fasciotomy
Classic compartment syndrome presentation requires emergent fasciotomy within 6 hours.
The 6 P's: Pain, Pressure, Pain with passive stretch, Paresthesias, Paralysis, Pulselessness. Delay beyond 6 hours risks Volkmann's contracture and amputation.
Question 4: What is the appropriate initial antibiotic for a Grade III open tibial fracture?
- Oral amoxicillin
- IV cefazolin alone
- IV cefazolin plus an aminoglycoside (Correct answer)
- IV vancomycin alone
Correct answer: IV cefazolin plus an aminoglycoside
Grade III open fractures require cefazolin (gram-positive) plus aminoglycoside (gram-negative) coverage.
Gustilo-Anderson: Grade I-II = cefazolin alone; Grade III = cefazolin + aminoglycoside. For farm injuries, add penicillin for Clostridium. Antibiotics within 1 hour of injury.
Question 5: 24 hours after femoral fixation, a patient develops sudden dyspnea, petechial rash on chest, and confusion. Most likely diagnosis?
- Pulmonary embolism
- Fat embolism syndrome (Correct answer)
- Compartment syndrome
- Hospital-acquired pneumonia
Correct answer: Fat embolism syndrome
The triad of respiratory distress, petechial rash, and neurological changes 24-72 hours after long bone fracture is classic for fat embolism syndrome.
FES occurs 24-72 hours after long bone fractures. The petechial rash on chest/axillae/conjunctivae is pathognomonic. Treatment is supportive. Early fracture fixation reduces incidence.
Question 6: What is the most appropriate action for a traumatic finger amputation?
- Place amputated part directly on ice
- Wrap in saline-moistened gauze, seal in bag, place on ice (Correct answer)
- Soak in warm saline
- Apply tourniquet to stump and discard part
Correct answer: Wrap in saline-moistened gauze, seal in bag, place on ice
Wrap in moist gauze, sealed plastic bag, then on ice maintains viability without frostbite from direct ice contact.
Cool ischemia time for digits is up to 12-24 hours if properly cooled. Direct ice causes frostbite. Major limbs tolerate only 6 hours of warm ischemia.
ATLS Musculoskeletal Trauma 2
A patient presents with a deformed, swollen thigh after a motorcycle collision.
Distal pulses are weak.
What is the most important initial step?