Pelvic and Femur Fractures: Hemorrhage, Pelvic Binders, and Traction Splints Practice Questions

25 multiple-choice questions on Pelvic and femur fractures: hemorrhage, pelvic binders, and traction splints 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. Most of the bleeding from an unstable pelvic ring fracture comes from:

   1. A. The external iliac arteries
   2. B. The abdominal aorta
   3. C. The renal arteries
   4. D. Pelvic veins and bone
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   Answer: D. Pelvic veins and bone

   Torn veins of the posterior pelvic plexus and fractured cancellous bone cause most pelvic hemorrhage, which is why reducing pelvic volume with a binder helps. Arterial bleeding occurs in a minority but is harder to control without angiography.

2. A motorcyclist was thrown forward, and his pelvis struck the fuel tank. He is hypotensive with pelvic pain. This mechanism most often causes:

   1. A. An open-book pelvic fracture
   2. B. A posterior hip dislocation
   3. C. A vertical shear fracture
   4. D. A lateral compression fracture
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   Answer: A. An open-book pelvic fracture

   A forward impact against the fuel tank drives the pubic bones apart, producing an anteroposterior compression (open-book) pelvic fracture that enlarges pelvic volume and can bleed heavily. Apply a pelvic binder and transport rapidly. Lateral compression fractures result from side impacts, vertical shear from a fall onto one leg, and posterior hip dislocation from a knee striking the dashboard with the hip flexed.

3. An open-book pelvic fracture is dangerous mainly because it:

   1. A. Drives bone into the bladder
   2. B. Shortens that leg
   3. C. Enlarges the pelvic volume
   4. D. Compresses the iliac arteries shut
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   Answer: C. Enlarges the pelvic volume

   When the pubic symphysis springs apart, pelvic volume increases dramatically and allows liters of blood to collect. Bladder injury can occur but is not the main threat to life. Leg shortening is typical of a vertical shear injury, and the pelvic vessels are torn and bleeding rather than compressed shut.

4. A fall from a ladder onto one leg drove one side of the pelvis upward. The leg on that side appears shortened. This pattern is a:

   1. A. Lateral compression fracture
   2. B. Vertical shear fracture
   3. C. Stable iliac wing fracture
   4. D. Coccyx compression fracture
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   Answer: B. Vertical shear fracture

   Vertical shear displaces one hemipelvis upward and is highly unstable, with major bleeding risk. Lateral compression results from side impact rather than a vertical load.

5. When assessing the pelvis of a crash victim with obvious pelvic deformity and hypotension, you should:

   1. A. Rock the pelvis to test its stability
   2. B. Apply a binder without springing it
   3. C. Press firmly on the symphysis twice
   4. D. Log roll the patient to inspect it
   Show answer

   Answer: B. Apply a binder without springing it

   When signs of an unstable pelvis are obvious, further manipulation adds nothing and can disrupt clots; stabilize it with a binder. Repeated rocking of the pelvis is the classic error.

6. Which finding on a male crash victim most suggests a pelvic fracture with urethral injury?

   1. A. Bilateral flank bruising
   2. B. A distended upper abdomen
   3. C. Blood at the urethral opening
   4. D. Pain referred to the left shoulder
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   Answer: C. Blood at the urethral opening

   Blood at the urethral opening, scrotal or perineal hematoma, and difficulty urinating suggest urethral disruption from a pelvic fracture. Left shoulder pain is a referred sign of splenic injury.

7. A 50-year-old was ejected in a rollover. She has no visible pelvic deformity, but she has pelvic pain, HR 128, and BP 84/56 mmHg. You should:

   1. A. Apply a binder based on these signs
   2. B. Give fluids and reassess before binding
   3. C. Wait for a visible pelvic deformity
   4. D. Delay a binder until after imaging
   Show answer

   Answer: A. Apply a binder based on these signs

   A high-energy mechanism with pelvic pain and shock is enough to suspect an unstable pelvic fracture, and a binder centered over the greater trochanters should go on before transport; it is low risk and reduces pelvic volume and bone movement. Fluids do not replace mechanical stabilization and should not delay it. Many unstable pelvic fractures show no obvious deformity, so waiting for one wastes time while she bleeds. Imaging happens at the hospital, and binders are routinely placed beforehand and removed only after imaging if no fracture is found. (ATLS 10th ed.; PHTLS 10th ed.)

8. A motorcyclist with an unstable pelvis has blood coming from the rectum and a laceration in the perineum. You should suspect:

   1. A. A simple perineal laceration
   2. B. Bleeding hemorrhoids
   3. C. An isolated urethral injury
   4. D. An open pelvic fracture
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   Answer: D. An open pelvic fracture

   A perineal, rectal, or vaginal wound in a patient with a pelvic fracture means the fracture communicates with the outside or with the bowel: an open pelvic fracture, which carries a high death rate from bleeding and later infection. Apply a binder, control external bleeding with pressure or packing, and transport to a trauma center with notice. In a high-energy pelvic fracture, a perineal wound cannot be assumed to be a simple laceration, and the rectal blood points to a bony fragment tearing the bowel. Hemorrhoids do not explain new bleeding after major trauma. A urethral injury causes blood at the urethral opening, not from the rectum. (ATLS 10th ed., pelvic fractures; PHTLS 10th ed.)

9. Along with applying a pelvic binder, which additional step helps close an open-book pelvis?

   1. A. Spread the legs apart widely
   2. B. Flex the hips to 90 degrees
   3. C. Bind the knees and feet
   4. D. Prop the knees with a pillow
   Show answer

   Answer: C. Bind the knees and feet

   Padding between the knees and binding the legs together with the feet slightly turned in helps reduce pelvic volume. Spreading the legs apart widens the pelvic ring.

10. After a pelvic binder is applied to a hypotensive patient with an unstable pelvis, the binder should be:

    1. A. Released every 10 minutes
    2. B. Left in place and not reopened
    3. C. Loosened if the patient is in pain
    4. D. Removed if BP improves
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    Answer: B. Left in place and not reopened

    Releasing the binder reopens the pelvis and can restart bleeding, so it stays on until hospital imaging and treatment. Improved BP shows the binder is working, not that it can be removed.

11. A 32-year-old has an unstable pelvis and a midshaft femur fracture on the same side, with HR 132 and BP 78/48 mmHg. The best way to immobilize him is with a:

    1. A. Binder plus a vacuum mattress
    2. B. Hare traction splint, then a binder
    3. C. Traction splint and no binder
    4. D. Femur splint first, binder later
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    Answer: A. Binder plus a vacuum mattress

    The pelvic fracture is the life threat, so the binder goes on first, centered over the greater trochanters, and the whole body, including the femur, is then immobilized in a vacuum mattress or on a scoop with padding. A bipolar traction splint pushes its ischial pad against the fractured pelvis, so a pelvic fracture is a contraindication to traction on that side. Omitting the binder leaves the pelvic bleeding uncontrolled. Splinting the femur first delays the step that addresses the bleeding most likely to kill him.

12. Before you apply a pelvic binder, you should remove objects such as keys and phones from the patient's front pockets because they:

    1. A. Will set off the CT scanner
    2. B. Make the binder too loose
    3. C. Must be logged as evidence
    4. D. Can cause pressure injury
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    Answer: D. Can cause pressure injury

    A binder applies firm, prolonged pressure over the greater trochanters, so hard objects in pockets can cause skin and soft tissue injury. Empty pockets quickly, then apply the binder over clothing if needed so it is not delayed. The other reasons are not why pockets are emptied.

13. To move a patient with a suspected unstable pelvic fracture onto a stretcher, the best method is to:

    1. A. Log roll the patient twice
    2. B. Lift by the belt and arms
    3. C. Use a scoop stretcher
    4. D. Have the patient stand up
    Show answer

    Answer: C. Use a scoop stretcher

    A scoop stretcher allows transfer with minimal pelvic motion; log rolling twists the pelvis and can dislodge clots. If a log roll is needed, limit it to one careful roll.

14. A 24-year-old construction worker fell and has a swollen, shortened, painful midthigh with severe spasm. The hip, knee, and ankle are uninjured. The best splint is a:

    1. A. Pillow splint
    2. B. Air splint
    3. C. Sling and swathe
    4. D. Traction splint
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    Answer: D. Traction splint

    Isolated midshaft femur fractures are the indication for traction, which overcomes the powerful thigh muscle spasm that causes overriding bone ends and pain. Air splints cannot control the thigh muscles.

15. A traction splint reduces pain and bleeding in a femur fracture mainly by:

    1. A. Overcoming thigh muscle spasm
    2. B. Applying cold to the thigh
    3. C. Compressing the femoral artery
    4. D. Closing the open wound edges
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    Answer: A. Overcoming thigh muscle spasm

    Muscle spasm causes the bone ends to override, grind, and tear tissue; traction pulls them back toward length. Traction does not work by compressing the femoral artery.

16. When applying a traction splint, manual traction should be held:

    1. A. Until the splint is measured
    2. B. Until mechanical traction is set
    3. C. For 30 seconds and then released
    4. D. Until distal pulses return
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    Answer: B. Until mechanical traction is set

    Releasing manual traction before the splint takes over allows the bone ends to override again, causing pain and further injury. Briefly pulling and then letting go defeats the purpose.

17. The Hare (bipolar) traction splint applies countertraction against the:

    1. A. Greater trochanter
    2. B. Ischial tuberosity
    3. C. Iliac crest
    4. D. Pubic symphysis
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    Answer: B. Ischial tuberosity

    The ischial pad of a bipolar frame rests against the ischial tuberosity, and the ankle hitch pulls against it. This is why a fracture of the pelvis or hip is a contraindication to its use.

18. A unipolar traction splint such as the Sager differs from a bipolar splint in that it:

    1. A. Has one shaft along the inner leg
    2. B. Cannot be used on adult patients
    3. C. Requires the knee to be flexed
    4. D. Uses a frame on both sides of the leg
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    Answer: A. Has one shaft along the inner leg

    A unipolar device has one shaft placed along the inner thigh, and some models can splint both femurs. A bipolar device such as the Hare has a frame on both sides of the leg.

19. With a Sager-type traction splint, the usual starting amount of traction is about:

    1. A. 50% of body weight
    2. B. 2% of body weight
    3. C. 25% of body weight
    4. D. 10% of body weight
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    Answer: D. 10% of body weight

    Manufacturers recommend about 10% of body weight, to a maximum of about 7 kg (15 lb), adjusted for patient comfort. A quarter of body weight would be excessive and could injure the knee and soft tissues.

20. A patient with a femur fracture has a traction splint in place. During transport, his pain increases and his foot becomes cool and pale. You should:

    1. A. Increase the traction to 30% of weight
    2. B. Remove the splint completely
    3. C. Reassess the splint and the PMS
    4. D. Ignore it as expected discomfort
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    Answer: C. Reassess the splint and the PMS

    A change in pain or distal perfusion requires immediate reassessment of the splint, straps, hitch, and limb position. Blindly increasing traction can worsen vascular injury.

21. A 40-year-old has a midshaft femur fracture, HR 128, BP 82/56, and a tension pneumothorax. The femur should be:

    1. A. Placed in a traction splint first
    2. B. Ignored until the hospital
    3. C. Stabilized on the board en route
    4. D. Splinted before decompression
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    Answer: C. Stabilized on the board en route

    Traction splinting takes time; in a critical patient, treat the life threat and secure the leg to a long board or scoop, then apply traction en route if time permits. Delaying decompression to splint the femur reverses the priorities.

22. Which femur injury is NOT appropriate for a traction splint?

    1. A. A midshaft fracture with spasm
    2. B. A closed fracture of the shaft
    3. C. A shaft fracture in a teenager
    4. D. A fracture of the femoral neck
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    Answer: D. A fracture of the femoral neck

    A femoral neck fracture is a hip fracture, and traction against the ischium would push on the injured area. The other injuries are midshaft fractures where traction is indicated.

23. A 16-year-old has an open midshaft femur fracture with a bone end protruding. A traction splint is applied. If the bone end slips back into the wound during traction, you should:

    1. A. Pull the bone back out of the wound
    2. B. Report it to the receiving hospital
    3. C. Release all the traction at once
    4. D. Stop and pack the wound tightly
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    Answer: B. Report it to the receiving hospital

    Open femur fractures may be splinted with traction; if the bone end retracts, the hospital needs to know because the contamination is now internal. Pulling the bone back out would cause further tissue damage.

24. When packaging a patient with a traction splint on one leg, you should:

    1. A. Secure the splint so it cannot shift
    2. B. Let the splint hang off the stretcher
    3. C. Release the traction to fit the cot
    4. D. Elevate the splint with the hip flexed
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    Answer: A. Secure the splint so it cannot shift

    Secure the splint to the stretcher or board so movement does not change the traction or jostle the fracture. Releasing the traction to fit the stretcher lets the bone ends override.

25. Which finding in a patient with a femur fracture most strongly suggests significant hidden blood loss?

    1. A. Mild thigh swelling with good PMS
    2. B. Pain on movement of the leg
    3. C. A strong pedal pulse on that side
    4. D. Tachycardia and cool, pale skin
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    Answer: D. Tachycardia and cool, pale skin

    Signs of shock indicate that the thigh, pelvis, or another site is hiding a large volume of blood. Mild swelling with intact PMS describes the fracture itself, not hemodynamic compromise.