Page 11 of 14
OR13.1-2 | Orthopaedic Procedural Skills — Practice Quiz
Click any question card to reveal the correct answer.
A 24-year-old man sustains a closed fracture of the distal radius after a fall on an outstretched hand. You apply a below-elbow plaster. Which principle is MOST important to ensure safety of the cast?
Correct. The joint-above-and-below rule dictates that both the joint proximal and distal to the fracture must be immobilised. For a distal radius fracture, this means the wrist (distal joint) and the forearm/elbow must be incorporated, while the MCP joints are left free.
A well-applied cast must immobilise the joint above and below the fracture. For a distal radius fracture, a below-elbow (short-arm) slab or POP must extend from below the elbow to the metacarpal heads, immobilising the wrist and leaving the MCP joints free.
The joint-above-and-below rule is the key safety principle: immobilise the joint proximal AND distal to the fracture. For a distal radius fracture, a short-arm slab incorporates the wrist (distal joint) and extends to below the elbow.
Click to reveal answer
While applying an above-elbow plaster to a child with a supracondylar fracture, the nurse notes the child's fingers have become progressively swollen, pale, and the child is crying with pain on passive extension of the fingers. What is the MOST appropriate immediate action?
Correct. Tight cast leading to compartment syndrome must be treated by immediately splitting and bivalving the cast and releasing all underlying padding. Waiting for pulse loss is dangerous — a normal pulse can be present even with compartment syndrome until late.
Pain on passive stretch of the fingers, pallor, and swelling after cast application are the earliest signs of compartment syndrome. The cast must be split immediately (bivalved) to release pressure before ischaemic muscle damage occurs. A normal pulse does not exclude compartment syndrome.
The triad of increasing pain, pallor, and pain on passive stretch signals acute compartment syndrome secondary to a tight cast. The cast must be split and bivalved immediately — the pulse can remain intact until very late, so relying on it is unsafe.
Click to reveal answer
A 35-year-old woman is brought in after a road traffic accident with a closed fracture of the femoral shaft. The team decides to apply a Thomas splint in the emergency room as a temporary measure before surgery. What is the primary purpose of applying a Thomas splint?
Correct. The Thomas splint applies longitudinal traction to the femoral shaft fracture. This reduces pain, decreases the thigh's ability to expand (limiting haematoma formation and blood loss up to 1–2 L), and reduces fat embolism risk during transport to the operating room.
The Thomas splint provides longitudinal traction to the femoral shaft fracture, reducing pain, blood loss into the thigh, and the risk of fat embolism during transport. It is a critical damage-control measure before definitive fixation.
The Thomas splint is a traction splint — its primary purpose is to apply longitudinal traction for pain control, blood loss limitation, and safe transport. It does not provide rigid fixation and is a temporising measure.
Click to reveal answer
A junior intern is about to apply a collar-and-cuff and figure-of-8 strapping to a patient with an undisplaced clavicle fracture and a suspected shoulder dislocation that has been reduced. For the shoulder strapping, which structure is the bandage primarily trying to support?
Correct. The weight of the upper limb acts as the main deforming force in clavicle fractures (the arm droops, displacing the lateral fragment downward). Strapping or a broad-arm sling supports the arm's weight, reducing this deforming pull and maintaining alignment.
A broad-arm sling or shoulder strapping after clavicle fracture/shoulder dislocation works by supporting the weight of the arm, relieving pull on the fractured clavicle or the reduced shoulder joint. A figure-of-8 bandage for clavicle fractures also corrects the drooping shoulder by retracting the shoulder backward.
The primary biomechanical goal of shoulder/clavicle strapping is to support the weight of the arm, which is the dominant deforming force pulling the lateral fragment down and anteriorly in clavicle fractures.
Click to reveal answer
A 28-year-old motorcyclist arrives in the emergency room after a high-speed collision. As you approach to insert a urinary catheter, you notice blood at the urethral meatus. What is the appropriate next step?
Correct. Blood at the urethral meatus is a cardinal sign of urethral trauma and absolutely contraindicates urethral catheterisation. A retrograde urethrogram should be performed if possible; if bladder decompression is urgent, a suprapubic catheter is placed. Urology consultation is mandatory.
Blood at the urethral meatus is a reliable clinical sign of urethral injury and is an absolute contraindication to urethral catheterisation. Blind catheter passage risks converting a partial tear into a complete rupture. Suprapubic catheterisation or urgent urology consultation is indicated.
Blood at the urethral meatus is an absolute contraindication to urethral catheterisation, regardless of technique or lubricant. Passing a catheter risks completing a partial urethral tear into a full rupture with potentially irreversible complications.
Click to reveal answer
During ATLS-guided management of a polytrauma patient, you follow the ABCDE approach. You successfully secure the airway with an endotracheal tube. You notice absent breath sounds on the left side with tracheal deviation to the right. What is the priority 'B' intervention?
Correct. Absent breath sounds on the left with tracheal deviation to the right indicates left-sided tension pneumothorax, a life-threatening emergency under ATLS 'B' (Breathing). Immediate needle thoracostomy at the left 2nd ICS, midclavicular line, releases tension and is followed by chest drain insertion.
In ATLS, tracheal deviation away from the silent hemithorax with absent breath sounds = tension pneumothorax until proven otherwise. Immediate needle thoracostomy (2nd intercostal space, midclavicular line) is the priority life-saving B intervention, followed by chest drain.
This presentation is a tension pneumothorax — absent breath sounds unilaterally with tracheal deviation to the opposite side. ATLS mandates immediate needle decompression at the 2nd ICS midclavicular line on the affected side. Do NOT wait for X-ray.
Click to reveal answer
A 19-year-old rugby player arrives after an open fracture of the tibia, with visible bone protruding through the wound. Which is the MOST time-critical non-surgical intervention according to evidence-based open fracture management?
Correct. IV antibiotics within 1 hour of injury (BOAST/BOS guidelines: co-amoxiclav for Gustilo I/II, add gentamicin for IIIA/B/C) significantly reduce infection risk. Splintage is applied to reduce pain and blood loss. Wound debridement should NOT be done in the ER — it is performed in the operating room.
Evidence-based open fracture management mandates IV antibiotics within 1 hour of injury to prevent deep infection. Appropriate splintage of the limb also reduces pain and blood loss. The wound should be photographed and covered without repeated examination in the emergency room.
Antibiotics within 1 hour is the most time-critical non-surgical intervention. ER wound debridement is contraindicated (done in OT). A wound swab delays antibiotics unnecessarily. Tourniquet is reserved for life-threatening haemorrhage, not a standard open tibial fracture.
Click to reveal answer
After applying a below-knee plaster-of-Paris to a 45-year-old woman with an ankle fracture, which neurovascular check finding at 30 minutes would MOST urgently require cast splitting?
Correct. Pain on passive stretch (passive dorsiflexion of toes stresses the deep posterior compartment of the leg) is the earliest and most reliable sign of impending compartment syndrome. This finding demands immediate cast splitting and bivalving, followed by reassessment.
Neurovascular checks after casting assess the 5 Ps: Pain, Pallor, Paraesthesia, Paralysis, Pulselessness. Pain on passive dorsiflexion of the toes is the earliest and most sensitive indicator of compartment syndrome under the cast. Pulse loss is a late, pre-gangrene sign.
Pain on passive stretch of the muscles within a compartment is the earliest clinical sign of compartment syndrome. Capillary refill of 2s is normal. Mild pre-existing swelling is expected. Reduced pin-prick sensation is important but passive-stretch pain is typically the earliest sign.
Click to reveal answer