TCRN Musculoskeletal and Wound Care Questions and Answers — Questions and Answers
Question 1: A patient with a closed tibial fracture after a motorcycle crash requires escalating doses of opioid analgesia. Which early clinical finding is most indicative of developing acute compartment syndrome?
- Absence of a distal pulse
- Pain that is out of proportion to the injury (Correct answer)
- Inability to move the toes (paralysis)
- A cool, pale extremity
Correct answer: Pain that is out of proportion to the injury
Pain out of proportion to the injury, especially pain with passive stretching of the muscles in the affected compartment, is the earliest and most sensitive sign of acute compartment syndrome. Pulselessness, paralysis, and pallor are all considered very late and ominous signs, indicating significant vascular compromise and nerve damage have already occurred.
Question 2: A patient arrives with a grossly contaminated Grade III open femur fracture. After controlling hemorrhage and ensuring hemodynamic stability, which intervention is the highest priority to prevent osteomyelitis?
- Covering the wound with a saline-moistened sterile dressing
- Obtaining a deep wound culture before irrigation
- Administering broad-spectrum intravenous antibiotics (Correct answer)
- Immediate surgical debridement in the operating room
Correct answer: Administering broad-spectrum intravenous antibiotics
Prompt administration of broad-spectrum intravenous antibiotics is a time-sensitive priority in managing open fractures to prevent infection, such as osteomyelitis. While covering the wound and surgical debridement are also critical steps, initiating systemic antibiotic therapy as soon as possible (ideally within 1-3 hours of injury) has been shown to significantly reduce infection rates. Wound cultures are typically obtained after initial irrigation.
Question 3: A patient is extricated from a structural collapse with severe crush injuries to both lower extremities. The trauma nurse should anticipate which hallmark laboratory finding and prioritize which intervention to prevent acute kidney injury?
- Hyperkalemia; administration of intravenous insulin and dextrose
- Elevated creatinine kinase (CK); aggressive intravenous fluid resuscitation (Correct answer)
- Hypocalcemia; administration of calcium gluconate
- Decreased hemoglobin; transfusion of packed red blood cells
Correct answer: Elevated creatinine kinase (CK); aggressive intravenous fluid resuscitation
The hallmark laboratory finding for rhabdomyolysis is a markedly elevated creatinine kinase (CK) level, often greater than 5 times the upper limit of normal. The breakdown of muscle releases myoglobin, which is nephrotoxic. The primary intervention to prevent acute kidney injury is aggressive intravenous fluid resuscitation to maintain high urine output and flush the myoglobin through the renal tubules. While electrolyte abnormalities like hyperkalemia occur, treating the underlying cause with fluids is the priority.
Question 4: A 22-year-old involved in a skiing accident has an isolated, closed femur fracture. Forty-eight hours after the injury, the patient becomes acutely confused, develops respiratory distress, and has a petechial rash across the chest and axillae. These findings are most characteristic of which complication?
- Compartment Syndrome
- Pulmonary Embolism
- Rhabdomyolysis
- Fat Embolism Syndrome (FES) (Correct answer)
Correct answer: Fat Embolism Syndrome (FES)
This patient is exhibiting the classic triad of Fat Embolism Syndrome (FES): neurologic changes (confusion), respiratory insufficiency (respiratory distress), and a pathognomonic petechial rash. FES typically occurs 24-72 hours after a long bone or pelvic fracture. The other options do not present with this specific combination of symptoms.
Question 5: A patient presents with a deep, contaminated puncture wound from a farm implement. Their tetanus immunization history is unknown. According to current guidelines, what is the most appropriate prophylaxis?
- Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine only
- Tetanus Immune Globulin (TIG) only
- Tdap vaccine and Tetanus Immune Globulin (TIG) (Correct answer)
- No immunoprophylaxis is needed if the wound is thoroughly irrigated
Correct answer: Tdap vaccine and Tetanus Immune Globulin (TIG)
For a patient with a contaminated, tetanus-prone wound and an unknown or incomplete (<3 doses) vaccination history, guidelines recommend administering both the Tdap vaccine for active immunity and Tetanus Immune Globulin (TIG) for immediate passive immunity. They should be given in separate syringes at different anatomical sites.
Question 6: A patient with a traumatic knee dislocation undergoes successful closed reduction in the emergency department. Distal pulses are strong and palpable post-reduction. What is the most critical next assessment to rule out a limb-threatening injury?
- Measuring an Ankle-Brachial Index (ABI) (Correct answer)
- Obtaining post-reduction radiographs
- Applying a knee immobilizer for comfort
- Performing hourly passive range of motion
Correct answer: Measuring an Ankle-Brachial Index (ABI)
Knee dislocations have a high incidence of popliteal artery injury, which can occur even with palpable distal pulses due to an intimal tear. The standard of care is to measure the Ankle-Brachial Index (ABI). An ABI of less than 0.9 warrants further vascular imaging, such as a CT angiogram. While post-reduction x-rays are necessary, assessing for vascular injury is the most critical priority to prevent limb loss.
TCRN Musculoskeletal and Wound Care Questions and Answers
A patient with a closed tibial fracture after a motorcycle crash requires escalating doses of opioid analgesia.
Which early clinical finding is most indicative of developing acute compartment syndrome?