Assessment: Life Threats Versus Limb Threats, DCAP-BTLS, the Six Ps, and Distal PMS Practice Questions

25 multiple-choice questions on Assessment: life threats versus limb threats, DCAP-BTLS, the six Ps, and distal PMS for paramedic and EMT students, from Chapter 38 (Orthopaedic Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A 28-year-old motorcyclist has an obviously angulated open femur fracture, snoring respirations, and cool, clammy skin. Your first priority is to:

   1. A. Open and manage the airway
   2. B. Splint the femur in a traction splint
   3. C. Cover the open wound with sterile gauze
   4. D. Check distal pulses in the injured leg
   Show answer

   Answer: A. Open and manage the airway

   Dramatic extremity injuries must not distract from the primary survey; an obstructed airway kills in minutes. Splinting the femur matters, but only after airway, breathing, and circulation are addressed.

2. A 40-year-old fell from a roof and has a deformed wrist, a respiratory rate of 32, absent breath sounds on the right, and BP 84/50. The wrist should be:

   1. A. Splinted before you move him
   2. B. Reduced before the primary survey ends
   3. C. Ignored until hospital arrival
   4. D. Splinted en route if time allows
   Show answer

   Answer: D. Splinted en route if time allows

   In a critical patient, life threats and rapid transport come first; isolated extremity injuries can be stabilized on the stretcher or splinted during transport. Taking time on scene to splint the wrist delays care for the tension pneumothorax and shock.

3. Which orthopaedic injury is most likely to be an immediate threat to life?

   1. A. Posterior hip dislocation
   2. B. Closed tibial shaft fracture
   3. C. Unstable pelvic fracture
   4. D. Anterior shoulder dislocation
   Show answer

   Answer: C. Unstable pelvic fracture

   Pelvic fractures can bleed liters into the retroperitoneum and cause hemorrhagic shock. A hip dislocation threatens the femoral head and sciatic nerve, a limb threat rather than a life threat.

4. Which injury is considered a limb threat that requires rapid transport even in an otherwise stable patient?

   1. A. Knee dislocation with a cool, pale foot
   2. B. Closed clavicle fracture with good PMS
   3. C. Ankle sprain with swelling and bruising
   4. D. Finger dislocation with normal sensation
   Show answer

   Answer: A. Knee dislocation with a cool, pale foot

   Loss of distal perfusion after a knee dislocation suggests popliteal artery injury, and limb salvage depends on restoring blood flow within hours. The other injuries have intact neurovascular function and can be splinted routinely.

5. During DCAP-BTLS of a crash victim's knee, you find a laceration over the joint that leaks clear, stringy, slightly oily fluid. This most strongly suggests:

   1. A. Subcutaneous fat
   2. B. A wound into the joint space
   3. C. Serum oozing from the wound edges
   4. D. Lymph from a torn skin vessel
   Show answer

   Answer: B. A wound into the joint space

   Clear, viscous, slightly oily fluid from a wound over a joint is synovial fluid, which means the laceration has entered the joint capsule. An open joint injury carries the same infection risk as an open fracture: cover it with a sterile dressing, splint the joint, give antibiotics if your protocol allows, and report it so it is surgically washed out. Subcutaneous fat shows as yellow globules in the wound rather than a stringy fluid. Serum oozing from wound edges is thin and watery, not stringy. Lymph from small skin vessels is a thin, light ooze and does not come from a joint.

6. When you assess the extremities in a trauma patient, you should compare the injured limb with:

   1. A. Normal values in a reference chart
   2. B. The patient's description of it
   3. C. Your own extremities
   4. D. The opposite, uninjured limb
   Show answer

   Answer: D. The opposite, uninjured limb

   Comparing sides reveals subtle swelling, deformity, color, or temperature differences and shortening. There is no reference chart for limb appearance, and the patient's own report may be unreliable after trauma.

7. Assessment of distal pulse, motor function, and sensation in an injured extremity should be performed:

   1. A. Before and after splinting
   2. B. After splint application
   3. C. At the receiving hospital
   4. D. Once, during the primary survey
   Show answer

   Answer: A. Before and after splinting

   Checking PMS first establishes a baseline, and rechecking afterward shows whether the splint or repositioning compromised the limb. Checking only afterward misses whether a deficit was caused by the injury or by your splint.

8. After you splint a fractured forearm, the patient's fingers become numb and dusky. Before the splint, PMS was normal. You should first:

   1. A. Elevate the arm and continue
   2. B. Apply a cold pack over the splint
   3. C. Add more padding over the splint
   4. D. Loosen the splint and recheck
   Show answer

   Answer: D. Loosen the splint and recheck

   A change after splinting suggests the splint is too tight or the limb is positioned poorly, so loosen and readjust it and then reassess. Elevating without loosening leaves the constriction in place.

9. To test sensation in the hand of an alert patient with a forearm injury, you should:

   1. A. Ask the patient to make a tight fist
   2. B. Lightly touch each fingertip
   3. C. Ask whether the hand feels tingly
   4. D. Check capillary refill in the nail beds
   Show answer

   Answer: B. Lightly touch each fingertip

   Light touch on several fingertips, with the patient's eyes closed or looking away, tests sensory function. Making a fist tests motor function, and capillary refill tests circulation.

10. A patient with a lower leg fracture cannot wiggle his toes. This finding indicates impaired:

    1. A. Distal circulation
    2. B. Sensory function
    3. C. Motor function
    4. D. Bone alignment
    Show answer

    Answer: C. Motor function

    Inability to move the toes on command indicates a motor deficit from nerve, muscle, or spinal injury, so test strength in both feet and compare sides. Distal circulation is judged by pulses, skin color, temperature, and capillary refill, not by movement. Sensory function is tested separately with light touch. Bone alignment is judged by inspection and palpation; a deformed limb may still move normally, and a straight one may not.

11. In the six Ps of extremity assessment as taught in this text (pain, pallor, paresthesia, pulses, paralysis, and a sixth P), the sixth P is:

    1. A. Pressure
    2. B. Position
    3. C. Pupils
    4. D. Perfusion
    Show answer

    Answer: A. Pressure

    In this text the sixth P is pressure, the tense, firm feel of swollen tissue that may signal rising compartment pressure. Many other references use poikilothermia (a cool limb) as the sixth P instead; both point to the same limb threat. Position and pupils are not part of the extremity assessment. Perfusion overlaps with pallor and pulses and is not listed as a separate P.

12. Paresthesia in an injured extremity is best defined as:

    1. A. Inability to move the limb
    2. B. Pale, cool skin over the limb
    3. C. Tingling or pins and needles
    4. D. A grating sound at the fracture
    Show answer

    Answer: C. Tingling or pins and needles

    Paresthesia is abnormal sensation that suggests nerve compression or ischemia. Inability to move the limb is paralysis, a separate and later P.

13. A 34-year-old has a deformed midshaft tibia. Gently palpating the injury site, you feel a grating sensation. You should:

    1. A. Move the limb to confirm the finding
    2. B. Stop and avoid eliciting it again
    3. C. Have the patient bear weight briefly
    4. D. Document it as a sprain
    Show answer

    Answer: B. Stop and avoid eliciting it again

    Crepitus confirms bone ends grinding together; repeating it causes pain and can damage vessels and nerves. Deliberately moving the limb to confirm crepitus is unnecessary and harmful.

14. A 52-year-old has a closed fracture of the lower leg with no distal pulse. The foot is pale and cool. The leg is severely angulated. You should:

    1. A. Splint it in the angulated position found
    2. B. Apply a tourniquet above the fracture
    3. C. Elevate the leg and transport
    4. D. Gently realign it to restore the pulse
    Show answer

    Answer: D. Gently realign it to restore the pulse

    A pulseless limb with an angulated long-bone fracture should be realigned with gentle in-line traction, which often restores circulation; stop if resistance or severe pain occurs. Splinting it as found accepts ongoing ischemia when a simple maneuver may relieve it.

15. Which finding most strongly suggests a fracture with nerve injury rather than a simple fracture?

    1. A. Numbness distal to the injury
    2. B. Swelling at the fracture site
    3. C. Pain when the limb is moved
    4. D. Bruising over the deformity
    Show answer

    Answer: A. Numbness distal to the injury

    Loss of sensation below the injury points to nerve damage from bone fragments, stretching, or swelling. Swelling, pain, and bruising occur with almost every fracture.

16. During the secondary assessment of a crash victim, you note one leg is shorter than the other and rotated outward. This finding suggests:

    1. A. A sprained ankle with swelling
    2. B. A knee ligament tear
    3. C. A fracture of the hip or femur
    4. D. A fracture of the fibula
    Show answer

    Answer: C. A fracture of the hip or femur

    Shortening and external rotation are classic findings of a proximal femur (hip) fracture. Ankle and knee injuries do not shorten the limb.

17. An unresponsive trauma patient cannot report pain. Which assessment finding is most helpful in identifying an extremity fracture?

    1. A. A weaker distal pulse in that limb
    2. B. Withdrawal to a nail bed press
    3. C. Capillary refill time in the fingers
    4. D. Deformity, swelling, or instability
    Show answer

    Answer: D. Deformity, swelling, or instability

    Without a pain report, you must rely on inspection and palpation for deformity, swelling, crepitus, and instability. A weak distal pulse or slow capillary refill tests perfusion rather than the presence of a fracture, and withdrawal to a nail bed press assesses the level of consciousness.

18. Which patient with an extremity injury has a mechanism that justifies a full rapid trauma assessment rather than a focused exam?

    1. A. A man who twisted his ankle stepping off a curb
    2. B. A driver ejected in a rollover crash
    3. C. A woman who hit her thumb with a hammer
    4. D. A teen with a wrist injury from a skateboard fall
    Show answer

    Answer: B. A driver ejected in a rollover crash

    Significant mechanisms such as ejection call for a head-to-toe search for hidden injuries. Isolated low-energy injuries can be assessed with a focused exam of the injured area.

19. A patient with a forearm fracture has a radial pulse that is weaker than on the uninjured side, and the hand is cool. You should:

    1. A. Treat it as a limb threat
    2. B. Recheck it at the hospital
    3. C. Massage the hand to warm it
    4. D. Ignore it if the pulse is present
    Show answer

    Answer: A. Treat it as a limb threat

    A diminished pulse and cool skin compared with the other side indicate compromised circulation and require prompt splinting, gentle realignment if angulated, and expedited transport. A palpable pulse does not exclude significant vascular injury.

20. Which question in the history of an older adult who fell and now has hip pain is most important for finding a hidden medical cause?

    1. A. Whether the hip has hurt before
    2. B. Whether she uses a walker at home
    3. C. Which side of the body she landed on
    4. D. What happened just before the fall
    Show answer

    Answer: D. What happened just before the fall

    Falls in older adults may be caused by syncope, dysrhythmia, stroke, or hypoglycemia, so ask about dizziness, chest pain, or palpitations before the fall. Prior hip pain is useful but does not identify the cause of this event.

21. When should a painful, swollen extremity of a patient with a minor isolated injury be exposed?

    1. A. On arrival at the hospital
    2. B. When bleeding becomes visible
    3. C. During the focused exam
    4. D. After the splint is applied
    Show answer

    Answer: C. During the focused exam

    Clothing must be removed or cut away to inspect for wounds, deformity, and swelling, or an open fracture will be missed. Waiting until bleeding is visible lets small puncture wounds go undetected.

22. A 25-year-old has an obvious ankle deformity after a fall. Her skin is warm, pink, and dry, distal pulses and sensation are normal, and she has no other complaints. This injury is best categorized as:

    1. A. A potentially life-threatening injury
    2. B. An isolated, non-life-threatening injury
    3. C. A limb threat that needs rapid transport
    4. D. A minor injury that needs no splinting
    Show answer

    Answer: B. An isolated, non-life-threatening injury

    With normal perfusion, intact distal PMS, and no other injury, she has an isolated extremity injury that is neither a life threat nor a limb threat. She can receive a careful focused exam, splinting, and pain management before transport. Calling it potentially life-threatening would rush care she can safely receive on scene. A limb threat requires signs such as a cool, pale, or pulseless foot or a deficit in sensation or movement, which she does not have. A deformed ankle is still a probable fracture or dislocation, so it is not minor and it must be splinted.

23. A patient's distal pulse cannot be palpated in a swollen ankle, but the foot is warm and pink with brisk capillary refill. You should:

    1. A. Apply traction to restore the pulse
    2. B. Note the findings and monitor closely
    3. C. Use a Doppler probe in the field first
    4. D. Treat it as an arterial injury and rush
    Show answer

    Answer: B. Note the findings and monitor closely

    Swelling can make pulses hard to feel; warmth, color, and capillary refill give additional evidence of perfusion. Traction is for a pulseless angulated long-bone fracture, not a swollen ankle with good perfusion.

24. Pain that persists in a fractured extremity even after splinting and is increasing over time should prompt you to suspect:

    1. A. Fat embolism syndrome
    2. B. An expected splint effect
    3. C. Developing compartment syndrome
    4. D. Delayed union of the fracture site
    Show answer

    Answer: C. Developing compartment syndrome

    Splinting usually reduces fracture pain, so pain that keeps rising after immobilization is a warning sign of rising compartment pressure. Assuming it is an expected splint effect delays recognition of a limb threat. Fat embolism causes breathing problems, confusion, and petechiae rather than rising limb pain, and delayed union is a problem of weeks to months, not hours.

25. When documenting an extremity injury, the most useful description includes:

    1. A. The likely x-ray result
    2. B. The cost of the splint used
    3. C. The patient's sports history
    4. D. Location, PMS, and findings
    Show answer

    Answer: D. Location, PMS, and findings

    Exact location, deformity, wounds, and PMS before and after splinting let hospital staff detect change. Predicting the x-ray result is speculation that adds little.