Page 12 of 14
OR13.1-2 | Orthopaedic Procedural Skills — Graded Quiz
Click any question card to reveal the correct answer.
A 7-year-old child is brought with a supracondylar fracture of the humerus (Gartland type III) that has been reduced and an above-elbow plaster applied. Two hours later, the child's hand is pale, the radial pulse is absent, but the fingers remain capillary-refill positive. What is the MOST appropriate next step?
Correct. An absent radial pulse after supracondylar fracture, even with a pink hand (collateral perfusion via anterior interosseous artery), requires immediate cast splitting. A pulseless pink hand mandates urgent K-wire fixation; if the pulse does not return, the brachial artery must be surgically explored. Do not simply observe — a pulseless limb in a child is a vascular emergency.
An absent radial pulse after supracondylar fracture reduction raises concern for brachial artery injury or tethering, even if the hand is still pink (indicating collateral circulation). The cast must be split and bivalved immediately. If the pulse does not return after cast splitting, urgent surgical exploration (brachial artery and K-wire fixation) is required. A pulseless pink hand warrants surgical intervention.
A pulseless hand after supracondylar fracture reduction is a vascular emergency. Even a pink hand with absent radial pulse indicates the brachial artery is compromised. Split the cast immediately; if the pulse does not return, urgent surgical exploration is required.
Click to reveal answer
A patient with a femoral shaft fracture in a Thomas splint arrives at a tertiary centre after 4 hours of transport. On assessment, there is no active haemorrhage visible but the thigh is markedly swollen, the patient is cold and clammy with a BP of 90/60 mmHg and HR 118/min. Following ATLS principles, which is the MOST urgent 'C' intervention?
Correct. Class III shock requires immediate establishment of IV access (two large-bore peripheral IV lines or central venous access) and blood resuscitation. The Thomas splint controls blood loss mechanically and should remain in place until surgical fixation. Urinary catheter insertion is a useful adjunct but follows vascular access.
A femoral shaft fracture can cause 1–2 litres of blood loss into the thigh. Class III haemorrhagic shock (BP 90/60, HR >110) requires large-bore IV access and aggressive fluid/blood product resuscitation as the 'C' (Circulation) priority in ATLS. The Thomas splint should remain in situ.
ATLS 'C' (Circulation) priority in haemorrhagic shock is IV access and fluid/blood resuscitation. Two large-bore IV cannulae are inserted immediately. CT angiography is premature before haemodynamic stabilisation.
Click to reveal answer
During a polytrauma simulation, a trainee is asked to insert an endotracheal tube (ETT) in a simulated patient as part of ATLS 'A' management. She successfully intubates but then inflates the cuff excessively. Which of the following is the MOST dangerous consequence of cuff over-inflation?
Correct. Over-inflated ETT cuffs exert pressure on the tracheal mucosa exceeding capillary perfusion pressure (>30 cmH2O), causing ischaemic necrosis. Long-term this leads to tracheal stenosis, tracheomalacia, or tracheo-oesophageal fistula. Recommended cuff pressure is 20–30 cmH2O.
Excessive ETT cuff pressure (>25–30 cmH2O) causes ischaemic pressure necrosis of the tracheal mucosa over the cuff site, risking tracheal stenosis, tracheomalacia, or tracheo-oesophageal fistula as delayed complications. Cuff pressure is routinely monitored in ICU settings.
ETT cuff over-inflation causes ischaemic pressure necrosis of the tracheal mucosa, with the most dangerous delayed complication being tracheal stenosis. Endobronchial migration is not caused by cuff over-inflation.
Click to reveal answer
A 32-year-old man is brought after a motorcycle accident with a suspected posterior dislocation of the hip. He has also sustained a closed femoral shaft fracture. Which neurological complication is specifically associated with posterior hip dislocation and must be checked before and after any reduction attempt?
Correct. The sciatic nerve runs posterior to the hip joint and is vulnerable to injury in posterior hip dislocations. The common peroneal division is more susceptible, causing foot drop (weakness of dorsiflexion and eversion) and sensory loss over the dorsum of the foot and first web space.
Posterior hip dislocation stretches or directly injures the sciatic nerve (or its main division, the common peroneal nerve) in up to 10–13% of cases. This presents with foot drop and sensory loss over the dorsum of the foot. Sciatic nerve function must be documented before and after reduction.
Posterior hip dislocation specifically endangers the sciatic nerve (and its common peroneal division). This causes foot drop and dorsal foot sensory loss — always check and document sciatic nerve function before and after reduction.
Click to reveal answer
After applying a circular above-knee plaster-of-Paris to a 55-year-old man with a distal femur fracture, you perform a neurovascular check 2 hours later. He reports escalating pain, his foot is cool, and there is no capillary refill in the toes. The cast appears intact externally. What is the correct sequence of actions?
Correct. This is critical limb ischaemia secondary to a tight cast. Immediately split and bivalve the cast and cut all padding to fully decompress the limb. If ischaemia does not resolve, urgent vascular surgery review and possible operative intervention (popliteal artery exploration) is needed.
Absent capillary refill, cool limb, and escalating pain under a cast indicates critical limb ischaemia from a tight cast or underlying vascular injury. The immediate action is to split and bivalve the entire cast AND cut all underlying padding to relieve constriction. If ischaemia persists after cast release, the vascular injury must be explored urgently.
Absent capillary refill with a cool foot under a cast = critical limb ischaemia requiring immediate cast splitting, bivalving, and padding release. Ordering Doppler or waiting for analgesia to work are dangerous delays.
Click to reveal answer
A medical student is observing the resuscitation of a polytrauma patient. After securing IV access and beginning fluids, the team inserts a urinary catheter. The student asks the registrar: 'What is the specific contraindication to urethral catheterisation that must always be checked before insertion?' The MOST complete correct answer is:
Correct. Blood at the urethral meatus is the absolute contraindication to urethral catheterisation. It signals urethral disruption (most commonly at the bulbomembranous junction in posterior urethral injuries or penoscrotal junction in anterior urethral injuries). A retrograde urethrogram confirms the diagnosis; suprapubic catheter is the safe alternative.
Blood at the urethral meatus, perineal bruising (butterfly bruising), and high-riding prostate on rectal examination are the classic triad of urethral injury signs. Blood at the meatus is the single most important finding that absolutely contraindicates urethral catheterisation.
Blood at the urethral meatus is the key contraindication. Haematuria in voided urine, pelvic fracture on X-ray, or BPH history do not individually contraindicate urethral catheterisation; they are risk factors that warrant careful assessment.
Click to reveal answer
A Gustilo-Anderson type IIIC open fracture of the tibia is identified: the bone is exposed, there is significant contamination, and the dorsalis pedis and posterior tibial pulses are absent. Aside from splintage, what defines IIIC specifically and dictates the operative priority?
Correct. Gustilo IIIC = vascular injury requiring repair. The absent pulses confirm this. The operative priority is vascular reconstruction (with or without temporary vascular shunt first), typically with simultaneous or subsequent skeletal stabilisation (external fixator). IIIC carries the highest amputation risk (~50%).
Gustilo-Anderson III classification: IIIA = adequate periosteal coverage despite extensive laceration; IIIB = periosteal stripping requiring soft-tissue coverage; IIIC = arterial injury requiring vascular repair. The arterial injury in IIIC is the limb-threatening emergency driving the operative sequence: vascular repair before orthopaedic fixation (or provisional external fixation first to stabilise for vascular repair).
Gustilo IIIC is specifically defined by arterial injury requiring vascular repair. Gross contamination and periosteal stripping characterise IIIA and IIIB respectively. The IIIC designation mandates urgent vascular surgery involvement.
Click to reveal answer
A 62-year-old woman has a below-knee plaster applied for a stable ankle fracture. On day 2 she phones complaining of aching and slight numbness in the foot but denies any severe pain or colour change. The best initial advice and plan is:
Correct. Any new numbness, tingling, or increasing pain under a cast requires same-day reassessment. The cast should be assessed and bivalved, windowed, or replaced depending on findings. Delayed review risks progression to compartment syndrome or pressure sore.
Mild aching and slight numbness on day 2 after below-knee POP may indicate early pressure or swelling under the cast and warrants urgent review for cast check and possible splitting or windowing. Instructing the patient to return for assessment is the safe response; ignoring it risks compartment syndrome.
Post-cast numbness is NOT normal and must not be dismissed. Same-day urgent review allows assessment of the cast fit and early splitting or bivalving before complications develop.
Click to reveal answer
A final-year student is asked to identify the correct site for peripheral IV cannulation as part of the 'C' step during a polytrauma resuscitation. The patient has obvious upper limb injuries bilaterally. Which alternative peripheral access site is most appropriate as first-line?
Correct. When antecubital fossa access is unavailable, the femoral vein and external jugular vein are the next peripheral IV alternatives. They allow rapid large-volume infusion. Intraosseous access is reserved for cardiac arrest or when IV access repeatedly fails. Central lines should not be the first attempt in a trauma resuscitation.
When bilateral upper limb IV access is unavailable due to injuries, the femoral vein (large-bore cannula at the groin) or external jugular vein are appropriate peripheral alternatives. Intraosseous access is used when venous access fails in cardiac arrest or in children. Central venous access (subclavian, internal jugular) follows if peripheral sites fail.
With bilateral upper limb injuries blocking antecubital access, the femoral vein or external jugular vein are the best peripheral alternatives. Intraosseous access is for cardiac arrest. Central venous lines are not the first choice in trauma resuscitation.
Click to reveal answer
Following ATLS primary survey, which step in the 'D' (Disability) assessment specifically uses the AVPU scale, and which clinical finding would prompt immediate neurosurgical consultation?
Correct. AVPU 'P' (responds only to pain) roughly correlates with GCS 8, which is a threshold for airway protection and concern for raised ICP. Unequal pupils (one fixed dilated) indicates uncal herniation — a neurosurgical emergency. Both together demand immediate CT head and neurosurgical consultation.
ATLS 'D' (Disability) involves rapid neurological assessment: AVPU (Alert, Voice, Pain, Unresponsive) or GCS, pupils (size, symmetry, reaction), and blood glucose. A GCS ≤8 or unresponsive on AVPU with unequal pupils (anisocoria) indicates raised intracranial pressure and mandates immediate neurosurgical consultation and CT head.
AVPU 'P' with unequal pupils = GCS approximately ≤8 with signs of herniation — this combination mandates immediate neurosurgical consultation. A GCS of 14 with equal pupils is monitored but not an immediate consult trigger.
Click to reveal answer