PHTLS - Prehospital Trauma Life Support Musculoskeletal Trauma — Questions and Answers
Question 1: What is the primary goal of splinting extremity fractures in the prehospital setting?
- To reduce the fracture to anatomic alignment
- To prevent further injury, reduce pain, and minimize hemorrhage (Correct answer)
- To provide definitive fracture treatment in the field
- To improve cosmetic appearance of the injured limb
Correct answer: To prevent further injury, reduce pain, and minimize hemorrhage
Splinting prevents further soft tissue and neurovascular injury, reduces pain by limiting movement, and helps control hemorrhage.
PHTLS identifies multiple benefits of proper splinting: prevention of further injury to muscles, nerves, and blood vessels; pain reduction by limiting movement at the fracture site; and hemorrhage reduction. Splinting is NOT intended to achieve anatomic reduction. The general principle is to splint in the position found.
Question 2: A patient has a closed femur fracture. How much blood can be lost internally from this single injury?
- 100-200 mL
- 500-750 mL
- 1,000-1,500 mL (Correct answer)
- 50-100 mL
Correct answer: 1,000-1,500 mL
A closed femur fracture can result in 1,000-1,500 mL or more of blood loss into the thigh compartment.
The thigh contains the largest muscle group in the body with extensive blood supply. This blood loss may not be externally visible, making it a significant source of occult hemorrhage. Traction splinting helps reduce blood loss by approximating bone ends and reducing compartment volume.
Question 3: When is a traction splint indicated in prehospital trauma care?
- For all lower extremity fractures
- For isolated midshaft femur fractures without hip or knee involvement (Correct answer)
- For open fractures with exposed bone
- For suspected pelvic fractures
Correct answer: For isolated midshaft femur fractures without hip or knee involvement
Traction splints are specifically indicated for isolated midshaft femur fractures, applying longitudinal traction to reduce muscle spasm and realign bone fragments.
Contraindications include fractures near the hip or knee joint, pelvic fractures, knee injuries on the same leg, and ankle/foot injuries preventing traction strap application. For bilateral femur fractures, individual traction splints are applied to each leg.
Question 4: What neurovascular assessment should be performed before and after splinting an extremity fracture?
- Blood pressure measurement in the affected extremity
- Assessment of pulse, sensation, and motor function distal to the injury (Correct answer)
- ECG monitoring of the affected limb
- Temperature comparison between both extremities
Correct answer: Assessment of pulse, sensation, and motor function distal to the injury
Distal pulse, sensation, and motor function must be assessed before and after splinting to detect any neurovascular compromise.
The neurovascular assessment (Pulse, Motor function, Sensation) is fundamental in PHTLS. If PMS is abnormal after splinting, the splint must be adjusted. Progressive loss of PMS during transport suggests evolving compartment syndrome or vascular compromise.
Question 5: How should an open fracture with exposed bone be managed in the prehospital setting?
- Push the bone back into the wound and splint
- Control hemorrhage, apply moist sterile dressing over the wound, and splint (Correct answer)
- Apply a tourniquet above and below the fracture site
- Irrigate the wound extensively with saline in the field
Correct answer: Control hemorrhage, apply moist sterile dressing over the wound, and splint
Open fractures require hemorrhage control, covering with a moist sterile dressing to prevent further contamination and drying, and immobilization with a splint.
PHTLS management includes: control hemorrhage with direct pressure; cover exposed bone with sterile dressings moistened with normal saline; splint without pushing bone back into the wound. Extensive field irrigation is not recommended as it delays transport.
Question 6: A trauma patient has a deformed ankle with no palpable dorsalis pedis pulse. What should the prehospital provider do?
- Immediately apply a traction splint
- Attempt gentle realignment to restore distal circulation, then splint (Correct answer)
- Transport without any intervention
- Apply a tourniquet above the knee
Correct answer: Attempt gentle realignment to restore distal circulation, then splint
When a deformed extremity has absent distal pulses, gentle realignment with inline traction may restore blood flow.
The displaced bone or joint may be compressing or kinking the artery. Gentle inline traction to realign the extremity often restores distal circulation. If the pulse does not return after one gentle attempt, splint in position and transport urgently.
Question 7: What is compartment syndrome and why is it significant in musculoskeletal trauma?
- Infection of the bone marrow
- Increased pressure within a fascial compartment that compromises circulation and nerve function (Correct answer)
- Displacement of fractured bone into a joint space
- Allergic reaction to splint materials
Correct answer: Increased pressure within a fascial compartment that compromises circulation and nerve function
Compartment syndrome occurs when swelling within a rigid fascial compartment raises pressure above capillary perfusion pressure, threatening tissue viability.
Without fasciotomy, irreversible muscle necrosis begins within 6-8 hours. The classic '6 Ps' include: Pain out of proportion, Pressure, Paresthesias, Paralysis, Pallor, and Pulselessness. Loss of pulse is a late finding. The anterior compartment of the lower leg is most commonly affected.
Question 8: Which of the following is a sign of vascular injury associated with an extremity fracture?
- Normal capillary refill in all digits
- Expanding hematoma at the fracture site (Correct answer)
- Mild swelling expected with any fracture
- Equal skin color bilaterally
Correct answer: Expanding hematoma at the fracture site
An expanding hematoma near a fracture site suggests arterial injury, as blood continues to accumulate under arterial pressure.
Certain fractures carry particularly high vascular injury risk: supracondylar humerus fractures (brachial artery), knee dislocations (popliteal artery, up to 40% incidence), and proximal tibia fractures. PHTLS emphasizes serial neurovascular assessments.
Question 9: A patient has bilateral femur fractures after a pedestrian versus vehicle collision. What is the primary concern?
- Inability to walk after recovery
- Life-threatening hemorrhagic shock from combined blood loss of 2,000-3,000 mL or more (Correct answer)
- Need for surgical fixation of both legs simultaneously
- Risk of fat embolism within the first hour
Correct answer: Life-threatening hemorrhagic shock from combined blood loss of 2,000-3,000 mL or more
Bilateral femur fractures can result in combined blood loss exceeding 3,000 mL, potentially causing Class III-IV hemorrhagic shock.
Each femur fracture can cause 1,000-1,500 mL of blood loss, so bilateral fractures may result in 2,000-3,000+ mL of hemorrhage. These patients frequently have additional injuries given the significant mechanism and should be assessed for pelvic, abdominal, thoracic, and head injuries concurrently.
Question 10: What is the appropriate management of an amputated body part for possible reimplantation?
- Place directly on ice to freeze the tissue
- Wrap in moist sterile dressing, place in plastic bag, then on ice without direct contact (Correct answer)
- Submerge in warm saline solution
- Leave at room temperature without wrapping
Correct answer: Wrap in moist sterile dressing, place in plastic bag, then on ice without direct contact
The amputated part should be wrapped in moist sterile gauze, sealed in a plastic bag, and placed on ice water to cool without direct freezing.
Direct contact with ice causes frostbite damage, making reimplantation impossible. Cool ischemia time for digits is approximately 12 hours, for major limbs approximately 6 hours. PHTLS emphasizes that care of the patient's life-threatening injuries always takes priority.
Question 11: How should a fracture near a joint be splinted differently from a midshaft long bone fracture?
- Joint fractures do not require splinting
- Splint the joint in the position found, immobilizing the bones above and below (Correct answer)
- Always straighten the joint before splinting
- Use only rigid splints for joint injuries
Correct answer: Splint the joint in the position found, immobilizing the bones above and below
Fractures near or involving joints should be splinted in the position found because attempts to straighten them risk further neurovascular injury.
Joint-area injuries present special concerns because major neurovascular structures run close to the joint. PHTLS teaches splinting in the position found, using padded splints conforming to the deformity. The exception is when there is no distal pulse.
Question 12: Why does PHTLS classify musculoskeletal injuries as lower priority during the primary survey unless hemorrhage is life-threatening?
- Musculoskeletal injuries never cause death
- Airway, breathing, and circulatory emergencies are more immediately life-threatening (Correct answer)
- Splinting can only be done at the hospital
- Fractures heal without any treatment
Correct answer: Airway, breathing, and circulatory emergencies are more immediately life-threatening
PHTLS prioritizes the ABCDE approach because airway obstruction, inadequate ventilation, and hemorrhage will kill the patient faster than most extremity injuries.
Most musculoskeletal injuries are not immediately life-threatening. Exceptions include massive hemorrhage from open fractures or amputations, bilateral femur fractures, and crush syndrome with hyperkalemia. Extremity injuries are typically addressed during the secondary survey.
PHTLS - Prehospital Trauma Life Support Musculoskeletal Trauma
What is the primary goal of splinting extremity fractures in the prehospital setting?
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