OR1.1-6 | Skeletal Trauma and Polytrauma Principles — Graded Quiz

Correct. A sucking chest wound is an open pneumothorax — addressed under 'B' (Breathing) in ATLS. A three-sided occlusive dressing prevents air entry during inspiration while allowing egress on expiration, preventing tension pneumothorax. SpO2 of 88% confirms breathing compromise requiring immediate action.

An open pneumothorax (sucking chest wound) must be sealed immediately as part of the 'B' (Breathing) step of ATLS primary survey. The three-sided dressing allows air egress while preventing air entry. Tension pneumothorax is addressed by needle decompression. This takes priority over IV fluids and further examination.

The sucking chest wound (open pneumothorax) is a life-threatening B (Breathing) problem. The three-sided dressing is the immediate intervention. SpO2 88% confirms the breathing problem takes priority once the airway (already patent as he is moaning) is confirmed.

Correct. START triage: breathing present + RR 22/min (not >30) + radial pulse palpable + follows commands = Yellow (Delayed). The patient can wait for treatment and must be reassessed periodically.

In START triage: if breathing is present (after repositioning if needed), RR <30/min, radial pulse present, and follows commands → the patient is Yellow (Delayed). Red (Immediate) requires RR >30/min OR absent radial pulse OR failure to follow commands in a breathing patient.

START triage algorithm: breathing present after repositioning → check RR → if <30 → check radial pulse → if present → check mental status → if follows commands → Yellow (Delayed).

Correct. This patient's parameters (HR 142, BP 78/52, UO 8 mL/hr, GCS 12) are consistent with Class III shock (30–40% blood loss, 1.5–2.0 L). Pelvic fractures are notorious for massive retroperitoneal bleeding — binder/pelvic packing is urgent.

Class III haemorrhagic shock (30–40% blood loss = 1.5–2.0 L in a 70 kg adult) presents with HR 120–140, BP falling (systolic 70–90), RR 30–40, UO 5–15 mL/hr, and confusion. Open-book pelvic fractures can lose 3–5 L of blood into the retroperitoneal space — here presenting as Class III.

HR 142, BP 78/52, UO 8 mL/hr = Class III haemorrhagic shock (1.5–2.0 L loss). Class IV would show BP <70, HR >140 with minimal urine. The pelvic fracture is the likely source.

Correct. With 7 hours warm ischaemia, global muscle necrosis, and arterial injury (Gustilo IIIC), MESS scoring strongly favours primary amputation. Reperfusion of non-viable muscle releases myoglobin, potassium, and toxins causing acute kidney injury and systemic inflammatory response that can be lethal.

The Mangled Extremity Severity Score (MESS) helps decide between limb salvage and amputation. Key factors: arterial injury + warm ischaemia >6 hours + extensive muscle loss = primary amputation is often life-saving and functionally superior. Prolonged ischaemia causes reperfusion injury, myonecrosis, and potentially fatal acute tubular necrosis/multi-organ failure.

Warm ischaemia >6 hours with global muscle necrosis and arterial injury in a contaminated limb is a strong indicator for primary amputation. Salvage attempts risk lethal reperfusion injury and systemic myoglobinuria.

Correct. The standard is IV antibiotics within 1 hour of injury for all open fractures. Delay beyond this significantly increases infection rates. For Gustilo I/II: cefazolin alone; for Type III: add aminoglycoside; for farm/soil (clostridial risk): add penicillin G.

EAST/BOAST guidelines recommend IV antibiotics within 1 hour of injury in open fractures — not at the time of surgery. Early antibiotics dramatically reduce wound infection rates. The antibiotic of choice for Type I/II is cefazolin; aminoglycosides are added for Type III; penicillin G is added for farm/soil contamination (clostridial cover).

OR known-trap: antibiotics within 1 hour — not at the time of surgery, not within 6 hours. A 3-hour delay in this case represents a management deficiency.

Correct. Knee dislocation has 20–40% risk of popliteal artery injury. Diminished pulses make this urgent — CT angiography is required immediately. Limb loss occurs within 6–8 hours of warm ischaemia. MRI ligament assessment follows after vascular integrity is confirmed.

Knee dislocation (complete multiligamentous disruption) is associated with popliteal artery injury in 20–40% of cases — the popliteal artery is tethered above and below the knee. Even with initial pulses, intimal tear can cause delayed thrombosis. CT angiography (or vascular surgery review with ABI <0.9) is mandatory in all knee dislocations to rule out vascular injury before MRI ligament assessment.

OR known-trap: knee dislocation → popliteal artery injury. Diminished distal pulses demand immediate vascular assessment (CT angiography). Common peroneal nerve injury causing foot drop is also a known association.

Correct. Failed closed reduction of hip dislocation (especially with associated femoral head fracture) mandates urgent open reduction. A Kocher-Langenbeck or Smith-Petersen approach allows removal of interposed fragments and ORIF. Delay increases AVN risk. THA is a salvage procedure, not primary treatment in a 60-year-old with fracture-dislocation.

Pipkin Type II fracture-dislocation (femoral head fracture above fovea centralis) often has interposed bone fragments preventing closed reduction. After one or two attempts at closed reduction, if unsuccessful, open reduction is mandatory. Repeated forceful attempts increase AVN risk. ORIF via surgical dislocation (Kocher-Langenbeck or Smith-Petersen) is required.

When closed reduction of a hip dislocation fails (especially Pipkin fracture-dislocation with likely interposed fragment), open reduction is the next step — not repeated closed attempts (which increase AVN risk) or prolonged traction.

Correct. The classic Gurr triad of fat embolism syndrome: respiratory distress (hypoxaemia, PaO2 <60 mmHg), petechial rash (axilla, chest, subconjunctivae), and cerebral dysfunction. Onset is 24–72 hours post-fracture of long bones.

The classic Gurr triad of fat embolism syndrome (FES): (1) petechial rash (especially axilla, subconjunctivae, chest), (2) respiratory distress (hypoxaemia), and (3) neurological deterioration (confusion, coma). FES typically presents 24–72 hours after long bone or pelvic fracture. Petechiae in 50–60% of cases is diagnostic.

Fat embolism syndrome classic triad (Gurr): hypoxaemia/respiratory distress + petechial rash + neurological dysfunction. Remember this peaks 24–72 hours after injury — early operative stabilisation of long bone fractures reduces FES incidence.

Correct. Pre-reduction neurovascular assessment — especially axillary nerve function (regimental badge area sensation, deltoid power) — is non-negotiable. Documenting any pre-existing nerve injury before reduction is clinically essential and protects against medico-legal issues if nerve deficit is discovered post-reduction.

Before any manipulation of a dislocation, a full neurovascular examination must be documented. For shoulder dislocation, this specifically includes axillary nerve function (sensation over the regimental badge area, deltoid contraction). Documenting pre-reduction neurovascular status is both clinically essential and medicolegally mandatory.

OR known-trap: always document neurovascular status BEFORE reduction of any dislocation. Axillary nerve injury occurs in up to 35% of anterior shoulder dislocations and must be identified and documented before manipulation.

Correct. Computer-assisted orthopaedic surgery (CAOS) / surgical navigation provides real-time intraoperative guidance using pre- or intraoperative imaging. It improves accuracy of implant placement, reduces radiation, and is particularly useful in complex periarticular and spinal surgery.

Computer-assisted orthopaedic surgery (CAOS) / surgical navigation is a major recent advance (OR1.6) that uses intraoperative imaging and software to guide implant placement with precision, reducing malunion, implant failure, and radiation. Other advances include robotic-assisted arthroplasty, biologic augmentation (PRP/BMPs), and minimally invasive fixation techniques.

The use of intraoperative navigation for sub-millimetre implant placement represents computer-assisted orthopaedic surgery — a key recent advance (OR1.6). BMPs, MIPO, and locked nailing are also advances but do not describe computerised navigation.