Specific Upper and Lower Extremity Injuries: Shoulder, Elbow, Wrist, Hip, Knee, and Ankle Practice Questions

25 multiple-choice questions on Specific upper and lower extremity injuries: shoulder, elbow, wrist, hip, knee, and ankle 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 23-year-old fell while snowboarding and holds his right arm away from his body, refusing to let it move toward his chest. The shoulder looks squared off. You suspect:

   1. A. Anterior shoulder dislocation
   2. B. Posterior shoulder dislocation
   3. C. Midshaft clavicle fracture
   4. D. Acromioclavicular separation
   Show answer

   Answer: A. Anterior shoulder dislocation

   Anterior dislocation is by far the most common shoulder dislocation; the humeral head sits forward, the shoulder loses its rounded contour, and the arm is held slightly abducted. A posterior dislocation holds the arm against the body, internally rotated.

2. In a patient with an anterior shoulder dislocation, the nerve most often injured is tested by checking sensation over the:

   1. A. Tip of the little finger
   2. B. Lateral deltoid area
   3. C. Web between thumb and index finger
   4. D. Palm at the base of the thumb
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   Answer: B. Lateral deltoid area

   The axillary nerve wraps around the humeral neck and supplies a patch of skin over the lateral deltoid, the regimental badge area. The web space between thumb and index finger tests the radial nerve.

3. A 38-year-old had a generalized seizure and now has severe shoulder pain with the arm held against the body and rotated inward. This presentation suggests:

   1. A. Anterior shoulder dislocation
   2. B. Rotator cuff strain
   3. C. Posterior shoulder dislocation
   4. D. Midshaft humerus fracture with spasm
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   Answer: C. Posterior shoulder dislocation

   Violent internal rotation from seizure or electric shock drives the humeral head backward. An anterior dislocation is held away from the body in external rotation, the opposite of this picture.

4. A patient has a separation of the acromioclavicular (AC) joint after falling onto the point of the shoulder. The best field treatment is:

   1. A. A traction splint
   2. B. A sling and swathe
   3. C. Immediate reduction
   4. D. A rigid forearm splint
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   Answer: B. A sling and swathe

   AC separations are managed by supporting the arm and limiting shoulder motion with a sling and swathe. Field reduction is not indicated for this injury.

5. A 45-year-old fell and has a midshaft humerus fracture. He cannot extend his wrist, which hangs limply. This finding indicates injury to the:

   1. A. Ulnar nerve
   2. B. Median nerve
   3. C. Radial nerve
   4. D. Axillary nerve
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   Answer: C. Radial nerve

   The radial nerve runs in the spiral groove of the humerus, and injury causes wrist drop. Axillary nerve injury is linked to shoulder dislocation and affects sensation over the deltoid.

6. A 6-year-old fell from a trampoline onto an outstretched arm and has a swollen, deformed elbow. The most dangerous associated complication of a supracondylar fracture is injury to the:

   1. A. Brachial artery
   2. B. Radial head
   3. C. Ulnar collateral ligament
   4. D. Olecranon bursa
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   Answer: A. Brachial artery

   Displaced supracondylar fragments can compress or tear the brachial artery and median nerve, leading to ischemia and Volkmann contracture. Check the radial pulse and hand perfusion and splint as found.

7. A 30-year-old has a dislocated elbow with the forearm displaced posteriorly and a weak radial pulse. You should:

   1. A. Reduce the elbow in the field at once
   2. B. Straighten the arm and splint it
   3. C. Apply a sling and let it hang down
   4. D. Splint as found and transport
   Show answer

   Answer: D. Splint as found and transport

   Elbow dislocations are not reduced in the field because the brachial artery and nerves are tightly crowded around the joint; splint in the position found and transport rapidly to a hospital that can reduce it. Straightening the arm can tear the vessels it is meant to protect.

8. A 68-year-old woman fell on an outstretched hand. Her wrist has a dinner fork deformity. The most likely injury is:

   1. A. A scaphoid waist fracture
   2. B. A distal radius fracture
   3. C. An elbow dislocation
   4. D. A metacarpal fracture
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   Answer: B. A distal radius fracture

   A Colles fracture of the distal radius displaces the fragment dorsally and produces the dinner fork appearance, especially in osteoporotic older adults. Scaphoid fractures cause snuffbox tenderness without that deformity. An elbow dislocation deforms the elbow, not the wrist. A metacarpal fracture, often from punching, deforms the hand rather than the wrist.

9. A 20-year-old fell on an outstretched hand and has tenderness in the anatomic snuffbox at the base of the thumb with no deformity. You should:

   1. A. Splint it as a scaphoid fracture
   2. B. Treat it as a minor wrist sprain
   3. C. Have him grip to test strength
   4. D. Tell him an x-ray is not needed
   Show answer

   Answer: A. Splint it as a scaphoid fracture

   Snuffbox tenderness suggests a scaphoid fracture, which may not show on early x-rays and risks avascular necrosis if missed. Dismissing it as a sprain is the classic mistake.

10. A 27-year-old punched a wall and has a swollen hand with a depressed knuckle over the little finger. This is most likely a:

    1. A. Scaphoid waist fracture
    2. B. Colles fracture
    3. C. Thumb dislocation at the base
    4. D. Fifth metacarpal fracture
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    Answer: D. Fifth metacarpal fracture

    A boxer's fracture of the fifth metacarpal neck results from striking a hard object with a closed fist. A wound over the knuckle from a tooth should also be treated as a high-risk bite.

11. A 25-year-old fell while water-skiing with his legs forced apart. His leg is held abducted and turned outward, and a firm bulge is felt in the groin. You suspect:

    1. A. Posterior hip dislocation
    2. B. Femoral neck fracture
    3. C. Anterior hip dislocation
    4. D. Pubic ramus fracture
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    Answer: C. Anterior hip dislocation

    Forced abduction and external rotation lever the femoral head out the front of the socket, so the leg rests abducted and externally rotated and the head can be felt as a firm mass in the groin, where it can press on the femoral artery, vein, and nerve. Check distal pulses and sensation and splint as found. A posterior dislocation, the more common type, holds the leg flexed, adducted, and turned inward. A femoral neck fracture also turns the leg outward but shortens it without a groin mass, usually in an older adult after a low-energy fall. A pubic ramus fracture causes groin pain but does not fix the leg in an abnormal position.

12. A patient with a posterior hip dislocation should be checked for injury to which nerve?

    1. A. Femoral nerve
    2. B. Sciatic nerve
    3. C. Obturator nerve
    4. D. Pudendal nerve
    Show answer

    Answer: B. Sciatic nerve

    The sciatic nerve runs directly behind the hip joint and can be stretched by the displaced femoral head, causing weakness of the foot and lower leg. Femoral nerve injury is more linked to anterior dislocation.

13. A hip dislocation is a time-sensitive emergency mainly because delayed reduction increases the risk of:

    1. A. Fat embolism
    2. B. Bladder rupture
    3. C. Avascular necrosis
    4. D. Knee joint infection
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    Answer: C. Avascular necrosis

    The blood supply to the femoral head is easily disrupted, and the risk of avascular necrosis rises sharply when reduction is delayed beyond about 6 hours. Fat embolism is linked to long-bone fractures, not dislocations.

14. A patient with a suspected posterior hip dislocation should be immobilized:

    1. A. As found, supported by pillows
    2. B. With the leg pulled straight
    3. C. In a traction splint
    4. D. With only a pelvic binder applied
    Show answer

    Answer: A. As found, supported by pillows

    Support the leg in its found position with pillows and blankets on a scoop stretcher or vacuum mattress, and recheck distal PMS. Pulling the leg straight forces the femoral head against the torn capsule and can stretch the sciatic nerve and the vessels supplying the femoral head. A traction splint pushes against the injured hip and is contraindicated. A pelvic binder is for pelvic ring fractures; on its own it does nothing to support the dislocated hip.

15. A 17-year-old basketball player twisted her knee. The kneecap is displaced to the lateral side and the knee is flexed. This is a:

    1. A. Knee dislocation
    2. B. Tibial plateau fracture
    3. C. Meniscus tear
    4. D. Patellar dislocation
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    Answer: D. Patellar dislocation

    Patellar dislocations are common in adolescents, usually laterally after a twisting injury with the knee flexed, and the displaced kneecap is visible on the outer side of the knee. A true knee dislocation displaces the tibia on the femur and is a high-energy injury that threatens the popliteal artery. A tibial plateau fracture follows a strong blow or axial load and causes swelling without a displaced kneecap. A meniscus tear causes pain and locking but no visible deformity.

16. A basketball player jammed his finger, and now the tip droops and he cannot straighten the last joint. This is a:

    1. A. Boxer fracture
    2. B. Scaphoid fracture
    3. C. Thumb dislocation
    4. D. Mallet finger
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    Answer: D. Mallet finger

    A blow to the tip of an extended finger can tear the extensor tendon (or pull off a bone fragment) at the last joint, so the fingertip droops and cannot be actively straightened. It is splinted with the last joint straight. Boxer and scaphoid fractures involve the hand and wrist bones.

17. A knee dislocation that has reduced by itself before your arrival should be treated as:

    1. A. A ligament injury with no vascular risk
    2. B. A possible popliteal artery injury
    3. C. A reduced patellar dislocation
    4. D. A knee sprain to splint and release
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    Answer: B. A possible popliteal artery injury

    Spontaneously reduced knee dislocations carry the same risk of arterial injury, and a palpable pulse does not exclude it. These patients need splinting and hospital vascular evaluation. A reduced knee dislocation is not just a ligament injury or a sprain, and it should not be confused with a patellar dislocation, which displaces only the kneecap and carries far less vascular risk.

18. A 35-year-old felt a pop in his knee while pivoting during soccer, and the knee swelled within an hour. The most likely injury is a:

    1. A. Fractured patella from a direct blow
    2. B. Ruptured Achilles tendon
    3. C. Torn anterior cruciate ligament
    4. D. Strained hamstring muscle
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    Answer: C. Torn anterior cruciate ligament

    A pop with pivoting followed by rapid swelling (hemarthrosis) is typical of an ACL tear. Patellar fractures result from a direct blow or forceful quadriceps contraction.

19. A 22-year-old has a tibial shaft fracture with a puncture wound over the shin. The fracture should be considered open because the tibia:

    1. A. Lies just under the skin
    2. B. Is wrapped in thick muscle
    3. C. Bears body weight
    4. D. Bleeds more than other long bones
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    Answer: A. Lies just under the skin

    The anteromedial tibia has little soft tissue over it, so fractures frequently break the skin and become open. It is not covered by thick muscle, and neither its weight-bearing role nor the amount it bleeds explains why a nearby puncture should be presumed to reach the fracture.

20. A 66-year-old who takes long-term steroids stumbled on a step. He has a gap just above the kneecap and cannot raise his straight leg. You should suspect:

    1. A. Achilles tendon rupture
    2. B. Anterior hip dislocation
    3. C. Quadriceps tendon rupture
    4. D. Peroneal nerve injury only
    Show answer

    Answer: C. Quadriceps tendon rupture

    A palpable gap above the patella with inability to do a straight-leg raise suggests rupture of the quadriceps tendon, which is more common in older adults and those on steroids or with kidney disease. Splint the knee straight and transport. The Achilles tendon is at the heel.

21. The most common mechanism of an ankle sprain is:

    1. A. Inversion of the foot
    2. B. Eversion of the foot
    3. C. Hyperextension of the toes
    4. D. A direct blow to the heel
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    Answer: A. Inversion of the foot

    Rolling the foot inward stretches the ligaments on the outer side of the ankle. Eversion injuries are less common and more often cause fractures.

22. A 50-year-old has a grossly deformed ankle fracture-dislocation with a pale, pulseless foot. Your protocol allows realignment, but after one gentle attempt the pulse is still absent. You should:

    1. A. Pull harder until the pulse returns
    2. B. Splint it and begin rapid transport
    3. C. Return it to the original deformity
    4. D. Apply a tourniquet above the ankle
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    Answer: B. Splint it and begin rapid transport

    One gentle attempt at in-line realignment is reasonable for a pulseless, deformed limb; if circulation does not return, splint the limb in the improved position, pad it, and transport rapidly to a center that can reduce it and repair a vessel, notifying the hospital that the foot is pulseless. Pulling harder or repeating attempts adds nerve, vessel, and soft-tissue damage without improving the odds. Returning the ankle to its original deformity increases the kinking of the vessels. A tourniquet stops what little flow remains and is used only for life-threatening bleeding. (PHTLS 10th ed.; local protocols vary on the number of attempts.)

23. A 16-year-old has a lateral patellar dislocation after a twisting fall, with good distal PMS. Your protocol allows field reduction of this injury. The correct technique is to:

    1. A. Flex the knee fully and push the patella laterally
    2. B. Twist the lower leg outward to unlock the knee
    3. C. Push the patella downward toward the foot
    4. D. Extend the knee while guiding the patella medially
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    Answer: D. Extend the knee while guiding the patella medially

    With the hip flexed to relax the quadriceps, slowly straighten the knee while pushing gently on the lateral edge of the patella toward the midline; it usually slides back into the groove with a clunk and immediate relief. Splint the knee in extension, recheck PMS, and transport for x-ray, because an osteochondral fracture is common. Stop if you meet resistance or the pain increases. Full flexion tightens the quadriceps and holds the patella out, and pushing it laterally moves it the wrong way. Twisting the lower leg outward recreates the mechanism that caused the dislocation. Pushing the patella toward the foot does not move it back over the femoral condyle. In a New York State review, EMTs reduced 83 of 90 patellar dislocations (92%) without reported complications.

24. A 26-year-old has an obvious dislocation of the middle finger at the proximal interphalangeal joint. Your protocol does not allow reduction. You should:

    1. A. Splint the finger as found
    2. B. Straighten it and buddy-tape it
    3. C. Pull it firmly into place
    4. D. Apply ice and leave it free
    Show answer

    Answer: A. Splint the finger as found

    Without protocol authorization, finger dislocations are splinted as found and reduced at the hospital, often after x-ray to exclude fracture. Forcing reduction can turn a dislocation into a fracture-dislocation.

25. An adult pedestrian was struck on the outside of the knee by a car bumper. The knee is swollen and painful, and he cannot bear weight. The most likely fracture is of the:

    1. A. Femoral neck at the hip
    2. B. Medial ankle malleolus
    3. C. Lateral tibial plateau
    4. D. Fifth metatarsal
    Show answer

    Answer: C. Lateral tibial plateau

    A blow to the outside of the knee forces it inward, driving the lateral femoral condyle down into the lateral tibial plateau, the classic bumper fracture. It enters the knee joint, swells quickly, and can injure the popliteal vessels or cause compartment syndrome, so splint the knee as found and recheck distal PMS. A femoral neck fracture follows a fall onto the hip, usually in an older adult. The medial malleolus is injured by twisting forces at the ankle, far from this impact. A fifth metatarsal fracture follows rolling the foot inward.