PHTLS - Prehospital Trauma Life Support Musculoskeletal Trauma Questions and Answers — Questions and Answers
Question 1: A 46-year-old pedestrian was struck by a vehicle and presents with instability and crepitus on gentle palpation of the pelvis. The patient is tachycardic and hypotensive. What is the MOST critical prehospital intervention for managing this patient's suspected injury?
- Rapid infusion of two liters of crystalloid fluid.
- Application of bilateral traction splints to the lower extremities.
- Application of a commercial pelvic binder or improvised sheet sling. (Correct answer)
- Log rolling the patient onto a long spine board for immobilization.
Correct answer: Application of a commercial pelvic binder or improvised sheet sling.
An unstable pelvic fracture can lead to life-threatening internal hemorrhage by increasing the volume of the pelvic cavity and causing bleeding from fractured bone surfaces and pelvic vasculature. Applying a pelvic binder is the primary intervention to stabilize the fracture, reduce pelvic volume, and help tamponade the bleeding. [10, 23]
Question 2: Which of the following is considered the most reliable and earliest sign of developing compartment syndrome in a conscious patient with a closed tibial fracture?
- Pallor of the foot distal to the injury.
- Absence of a pedal pulse.
- Pain that is out of proportion to the injury and unrelieved by standard measures. (Correct answer)
- Paresthesia or a 'pins and needles' sensation in the toes.
Correct answer: Pain that is out of proportion to the injury and unrelieved by standard measures.
The earliest and most significant finding of acute compartment syndrome is severe pain that is disproportionate to the physical findings of the injury. [16, 17, 20] This pain is often described as deep, burning, and is not relieved by immobilization or typical doses of analgesics. The other classic signs, such as pallor, pulselessness, and paresthesia, are typically later and more ominous findings. [16]
Question 3: A 24-year-old has an obviously deformed, closed fracture of the right forearm after a fall. According to PHTLS principles, which assessment is mandatory immediately before AND after applying a rigid splint?
- Blood pressure in the affected arm.
- Pulse, motor function, and sensation (PMS) distal to the injury. (Correct answer)
- Capillary refill time in the nail beds of both hands.
- Range of motion of the wrist and elbow.
Correct answer: Pulse, motor function, and sensation (PMS) distal to the injury.
Assessing distal pulse, motor function, and sensation (PMS), also known as CSM, is critical both before and after splinting any extremity fracture. [1, 24] The 'before' assessment establishes a baseline, and the 'after' assessment ensures that the splint has not compromised neurovascular function to the limb.
Question 4: Application of a traction splint is indicated for an isolated, mid-shaft femur fracture. In which of the following situations is a traction splint contraindicated?
- The patient also has a suspected fracture of the ipsilateral tibia. (Correct answer)
- The patient has an open femur fracture with minimal bleeding.
- The patient is unconscious with a GCS of 7.
- The patient is hypotensive and tachycardic.
Correct answer: The patient also has a suspected fracture of the ipsilateral tibia.
A traction splint is contraindicated if there is a suspected fracture to the pelvis, hip, knee, tibia, or fibula on the same side as the femur fracture. [1, 7, 8] The splint applies force against the ankle and the pelvis/hip; a fracture in the lower leg would prevent the effective application of traction and could worsen the distal injury.
Question 5: You are managing a 38-year-old patient with a traumatic amputation of their left hand. After controlling hemorrhage, you recover the amputated part. What is the proper procedure for preserving the part for potential re-plantation?
- Place the hand directly into a container of ice water to keep it cold.
- Wrap the hand in a dry sterile dressing, place it in a plastic bag, and give it to the flight crew.
- Wrap the hand in saline-moistened gauze, place it in a sealed plastic bag, and place the bag in a cooler with ice. (Correct answer)
- Clean the part thoroughly with betadine before wrapping it for transport.
Correct answer: Wrap the hand in saline-moistened gauze, place it in a sealed plastic bag, and place the bag in a cooler with ice.
The proper procedure is to keep the amputated part cool and moist without causing frostbite or water damage. This is achieved by wrapping the part in saline-moistened gauze, placing it in a sealed waterproof bag, and then placing that bag in a second container with ice or cold packs. [25, 26, 27] The part should never be placed directly on ice or immersed in water. [27]
Question 6: You are treating a patient with a severe open fracture of the tibia, with a 2-inch bone end protruding through the skin. After controlling major hemorrhage, what is the most appropriate management for the wound itself?
- Attempt to gently push the bone end back under the skin to prevent drying.
- Vigorously irrigate the wound with sterile saline to remove all visible debris.
- Apply a tourniquet proximal to the wound to prevent infection.
- Cover the wound and exposed bone with a sterile, saline-moistened dressing. (Correct answer)
Correct answer: Cover the wound and exposed bone with a sterile, saline-moistened dressing.
The priority for managing an open fracture in the prehospital setting, after hemorrhage control, is to prevent further contamination. This is best accomplished by covering the wound with a sterile dressing. [5, 6] Moistening the dressing with sterile saline can help prevent the dressing from adhering to the exposed bone and tissues. The bone should not be pushed back into the wound in the field. [15]
PHTLS - Prehospital Trauma Life Support Musculoskeletal Trauma Questions and Answers
A 46-year-old pedestrian was struck by a vehicle and presents with instability and crepitus on gentle palpation of the pelvis.
The patient is tachycardic and hypotensive.
What is the MOST critical prehospital intervention for managing this patient's suspected injury?