ITLS Extremity Trauma Management 2 — Questions and Answers
Question 1: A patient has a closed femur fracture with significant thigh swelling. How much blood can be lost into the thigh from this injury alone?
- 250-500 mL
- 500-750 mL
- 1000-1500 mL (Correct answer)
- 2500-3000 mL
Correct answer: 1000-1500 mL
A closed femur fracture can result in 1000-1500 mL of blood loss into the thigh, which represents a Class II to Class III hemorrhage and can cause hypovolemic shock.
The femur is the largest bone in the body, surrounded by large muscle groups with an extensive vascular supply. A fracture disrupts the nutrient artery within the bone and damages surrounding soft tissue vessels. The thigh's fascial compartments can expand significantly, accommodating 1000-1500 mL of blood before external swelling becomes obvious. Bilateral femur fractures can cause Class III-IV hemorrhagic shock (2000-3000 mL loss). ITLS teaches that a swollen, tense thigh after trauma indicates significant hemorrhage even without external bleeding. A traction splint (e.g., Hare, Sager, or CT-6) reduces the fracture, decreases the intracompartmental volume, and helps tamponade bleeding. Pain management and volume resuscitation should accompany splinting. Patients with isolated femur fractures can deteriorate rapidly, and providers should not be deceived by the absence of external hemorrhage.
Question 2: What is the correct application technique for a traction splint on a midshaft femur fracture?
- Apply traction at the hip and secure at the knee
- Secure the ischial pad at the groin, apply manual traction to realign, then apply mechanical traction at the ankle (Correct answer)
- Apply the splint without any traction to avoid further injury
- Wrap the splint around both legs for bilateral stabilization
Correct answer: Secure the ischial pad at the groin, apply manual traction to realign, then apply mechanical traction at the ankle
Traction splint application involves anchoring the ischial pad against the ischial tuberosity, applying manual traction to realign the limb, then transferring to mechanical traction via the ankle hitch until muscle spasm is overcome and the patient reports pain relief.
Proper traction splint application for midshaft femur fractures follows a systematic approach: (1) Assess distal neurovascular status (pulses, sensation, movement, color). (2) Apply manual traction at the ankle while a partner positions the splint. (3) Place the ischial pad firmly against the ischial tuberosity (sit bone)—this provides the counter-traction anchor. (4) Secure the ankle hitch. (5) Apply mechanical traction until muscle spasm is overcome, typically 10-15 pounds or until the patient reports significant pain relief. (6) Secure the leg to the splint with straps. (7) Reassess distal neurovascular status. Contraindications include fractures at or near the knee or ankle, hip dislocation, and pelvic fractures. The traction splint works by overcoming the powerful thigh muscle spasm that causes bone fragment overlap, reducing the fracture and decreasing hemorrhage by reducing the compartment volume.
Question 3: During assessment of a forearm injury, you find the patient cannot extend their wrist or fingers and has numbness over the dorsal first web space. Which nerve is likely injured?
- Median nerve
- Ulnar nerve
- Radial nerve (Correct answer)
- Musculocutaneous nerve
Correct answer: Radial nerve
The radial nerve controls wrist and finger extension and provides sensation to the dorsal first web space. Wrist drop with this sensory pattern indicates radial nerve injury, commonly associated with humeral shaft fractures.
The radial nerve is the most commonly injured peripheral nerve in upper extremity trauma. It courses through the spiral groove of the humerus, making it vulnerable to midshaft humeral fractures. Motor function: wrist extension, finger extension (MCP joints), thumb extension, and forearm supination. Sensory: dorsal aspect of the first web space (anatomical snuffbox area) is the autonomous zone. Wrist drop (inability to extend the wrist against gravity) is the hallmark finding. Median nerve injury would cause loss of thumb opposition, thenar atrophy, and decreased sensation in the palmar surface of the first three fingers. Ulnar nerve injury causes clawing of the ring and small fingers, loss of finger abduction/adduction, and decreased sensation of the small finger. ITLS providers should document neurovascular status before and after any splinting to detect injury or compromise.
Question 4: A patient has an open fracture of the tibia with bone visible through the wound. What is the correct prehospital management sequence?
- Push the bone back in, then splint and wrap
- Control bleeding, cover the wound with a sterile moist dressing, splint in position found, and transport (Correct answer)
- Irrigate the wound with saline, reduce the fracture, then apply a rigid splint
- Apply a tourniquet above the knee regardless of bleeding status
Correct answer: Control bleeding, cover the wound with a sterile moist dressing, splint in position found, and transport
Open fractures are managed by controlling hemorrhage, covering the exposed bone with a sterile moist dressing to prevent desiccation, splinting without attempting reduction, and rapid transport for surgical management.
Open (compound) fractures have a direct communication between the fracture site and the external environment, creating high risk of deep bone infection (osteomyelitis). ITLS prehospital management includes: (1) Control bleeding with direct pressure—tourniquets only for life-threatening hemorrhage uncontrolled by pressure. (2) Do not push exposed bone back through the wound, as this introduces contaminants deep into the wound. (3) Cover the wound and exposed bone with a sterile dressing moistened with normal saline to prevent tissue desiccation. (4) Splint the extremity in the position found, immobilizing the joints above and below the fracture. (5) Monitor distal neurovascular status. (6) Transport promptly—definitive management requires surgical irrigation, debridement, and IV antibiotics. Photographing the wound before covering can be helpful for the surgical team. These patients need antibiotics within one hour of injury for optimal outcomes.
Question 5: What are the five P's of neurovascular compromise that ITLS providers must assess in extremity injuries?
- Pressure, Pulse, Position, Perfusion, Protection
- Pain, Pallor, Pulselessness, Paresthesia, Paralysis (Correct answer)
- Pulse, Pupils, Pain, Posture, Perspiration
- Perfusion, pH, Pressure, Pulse oximetry, Pain scale
Correct answer: Pain, Pallor, Pulselessness, Paresthesia, Paralysis
The five P's of neurovascular compromise are Pain (especially with passive stretch), Pallor, Pulselessness, Paresthesia (numbness/tingling), and Paralysis, assessed to detect compartment syndrome or vascular injury.
The five P's represent a progression of neurovascular compromise: Pain (earliest sign, classically out of proportion to the injury, worsened by passive stretch of involved muscles), Pallor (skin becomes white or mottled as blood supply decreases), Pulselessness (diminished then absent distal pulses as arterial flow is compromised), Paresthesia (numbness and tingling from nerve ischemia), and Paralysis (late finding indicating prolonged ischemia of motor nerves and muscles). In ITLS, these are assessed before and after splinting, during transport, and at hospital handoff. Compartment syndrome—elevated pressure within a fascial compartment compromising perfusion—progresses through these stages. Pulselessness and paralysis are late, ominous signs indicating tissue may already be irreversibly damaged. Pain with passive stretch of the involved compartment's muscles is the earliest and most sensitive clinical sign.
Question 6: A patient has sustained a posterior hip dislocation in a head-on MVC. In what position will the affected leg typically be found?
- Extended, externally rotated, and abducted
- Flexed, internally rotated, and adducted (Correct answer)
- Extended, neutral rotation
- Flexed, externally rotated, and abducted
Correct answer: Flexed, internally rotated, and adducted
Posterior hip dislocation classically presents with the leg flexed, internally rotated, and adducted, as the femoral head displaces posteriorly behind the acetabulum.
Posterior hip dislocation accounts for approximately 90% of traumatic hip dislocations and commonly results from dashboard impact in an MVC, where the flexed knee strikes the dashboard and the force transmits axially through the femur. The femoral head is driven posteriorly out of the acetabulum. The classic presentation is a shortened leg that is flexed at the hip, adducted (drawn toward midline), and internally rotated. The sciatic nerve runs directly behind the hip joint and is injured in 10-20% of posterior dislocations, causing foot drop and posterior thigh numbness. ITLS management includes: immobilize in the position found (do not attempt reduction in the field), check distal neurovascular status, and transport urgently. Avascular necrosis of the femoral head increases significantly if reduction is delayed beyond 6 hours. Anterior dislocations present with the opposite position: extended, externally rotated, and abducted.
ITLS Extremity Trauma Management 2
A patient has a closed femur fracture with significant thigh swelling.
How much blood can be lost into the thigh from this injury alone?