QUESTION	% Correct		p value
	PRE	POST
1. A thirty-year-old man has been involved in a road traffic accident one hour ago. He arrives to the casualty ward unconscious. He also has an open fracture of the left tibia, with a bone protruding through the skin. The initial assessment of this patient should entail:
a. complete history and physical examination, proceeding methodically from head to toe.	80.7	88.6	0.15
b. examine the abdomen first, as this is the most likely site of internal bleeding.	92.8	98.9	0.06
c. assess airway, breathing, and circulation first, before undertaking more detailed exam.	95.2	100	0.05
d. check the BP first. If this is low, examine the abdomen for internal bleeding.	86.7	93.2	0.16
e. examine the most obvious injury first, which is the open leg fracture.	90.4	94.3	0.33
2. What statements about the initial assessment of the trauma patient are true?
a. The primary survey to look for immediate life-threatening injuries should take 1–5 minutes.	85.5	96.6	0.01
b. The primary survey to look for immediate life-threatening injuries should take 25–30 minutes.	98.8	98.9	1.00
c. A detailed secondary survey should be performed after immediately life threatening injuries have been addressed.	86.7	92.0	0.26
d. A thorough history and methodical physical exam are the best initial approach.	85.5	95.5	0.03
e. The primary survey addresses difficulties with airway, breathing, and circulation.	85.5	94.3	0.06
3. Initial evaluation for airway obstruction can include:
a. listen for stridor or gurgling sounds.	89.2	94.3	0.22
b. feel for air movement with your hand over the patient’s mouth.	50.6	94.3	< 0.001
c. see how well the patient can speak.	20.5	60.2	< 0.001
d. visualize the vocal cords with a laryngoscope.	86.7	85.2	0.77
e. listen over the chest for breath sounds.	81.9	79.5	0.69
4. Maneuvers to establish a patent airway include:
a. suctioning of the mouth.	90.4	94.3	0.33
b. placing patient in a decubitus position (on side).	63.9	88.6	< 0.001
c. placement of a chest tube.	91.6	87.5	0.39
d. endotracheal intubation.	79.5	92.0	0.02
e. chin lift maneuver.	80.7	94.3	0.007
5. A twenty-year-old male fell from a roof top at a construction site. He is rushed in to your casualty ward. He is awake and can speak, but is extremely short of breath. He complains of pain in his chest and left abdomen. His systolic pressure is 60. Which of the following is true?
a. The next step should be to listen for breath sounds.	57.8	63.6	0.44
b. The next step should be to examine the abdomen.	48.2	70.4	0.003
c. Tension pneumothorax is a likely diagnosis.	66.3	92.0	< 0.001
d. Treatment may need to include the placement of a chest tube.	65.1	92.0	< 0.001
e. Diagnostic peritoneal lavage (DPL) should be performed as the next step.	57.8	42.0	0.04
6. A thirty-year-old male is rushed into your casualty ward in a semi-conscious state. He has multiple injuries, a pulse of 120, and systolic BP of 60. Appropriate treatments to reverse his state of shock include:
a. Administer steroids for the head injury.	71.1	95.5	< 0.001
b. Place a 20–22 gauge i.v.	71.1	94.3	< 0.001
c. Place a 16–18 gauge i.v.	59.0	92.0	< 0.001
d. Administer 500 mls of fluids over 1–2 hours.	96.4	97.7	0.67
e. Administer one liter of fluids over 15–30 minutes.	94.0	97.7	0.27
7. In a patient in shock after blunt trauma in which there are no open wounds and no external bleeding, possible sources of internal bleeding to account for the shock include:
a. intracerebral bleeding.	68.7	86.4	0.005
b. haemothorax.	67.5	88.6	< 0.001
c. intra-abdominal bleeding.	100	98.9	1.00
d. fracture of the femur.	59.0	69.3	0.16
e. forearm fracture.	96.4	95.5	1.00
8. After a patient has had severe head injury, useful treatments include:
a. Administer steroids in all cases.	51.8	96.6	< 0.001
b. Administer mannitol in all cases.	59.0	88.6	< 0.001
c. Administer steroids only if BP is normal.	86.7	95.5	0.04
d. Administer mannitol only if BP is normal.	42.2	85.2	< 0.001
e. Make sure patients in shock are well resuscitated.	74.7	94.3	< 0.001
9. In patients with head injury who had prolonged unconsciousness (e.g. 5 days or more), useful treatments to prevent life-threatening complications while the patient is recovering include:
a. Assure adequate nutrition, by NG tube if necessary.	85.5	94.3	0.06
b. Turn patient every 2–4 hours to prevent decubitus ulcers.	81.9	93.2	0.03
c. Administer antibiotics to prevent pneumonia.	26.5	23.9	0.69
d. Administer steroids to promote healing of the brain.	65.1	93.2	< 0.001
e. Administer mannitol each day until patient is out of coma.	84.3	83.0	0.81
10. Which of the following statements about chest tubes (tube thoracostomy) are true?
a. Is often needed in blunt, but not penetrating trauma.	91.6	87.5	0.39
b. Is a frequently needed life-saving maneuver in chest trauma.	89.2	94.3	0.22
c. If a chest tube in not available for a tension pneumothroax, one can temporize by placing a needle in the second intercostal space anteriorly.	71.1	97.7	< 0.001
d. One should always wait for a sterile bottle set up.	96.4	98.9	0.36
e. If a sterile bottle set up is not available, one can temporize by putting the outside of the tubing into a basin of water on the floor.	75.9	90.9	0.008
11. In abdominal trauma:
a. peritoneal signs are often subtle.	67.5	87.5	0.002
b. the primary factor in assessing is the accurate diagnosis of a specific type of injury.	66.3	90.9	< 0.001
c. penetrating injuries are more difficult to assess.	85.5	83.0	0.64
d. take precedence over chest injuries.	96.4	96.6	1.00
e. non-penetrating trauma is more common than penetrating trauma.	73.5	83.0	0.13
12. A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room, he is awake, alert, and appears frightened, but is in no distress. The chest radiograph suggests an air fluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest.
a. Place a left chest tube.	50.6	45.5	0.50
b. Do immediate thoracotomy.	68.7	79.5	0.10
c. Esophagogastroscopy is essential for the diagnosis.	68.7	88.6	0.001
d. Immediate laparotomy is indicated.	28.9	63.6	< 0.001
e. Remove and replace the nasogastric tube and perform diagnostic peritoneal lavage.	68.7	83.0	0.03
13. A patient has been stabbed in the anterior abdomen. He has no intra-abdominal symptoms or signs. Intra-abdominal injury is ruled out by:
a. peritoneal lavage.	44.6	18.2	< 0.001
b. probing of the wound to determine the tract.	66.3	93.2	< 0.001
c. ultrasound investigation.	62.7	61.4	0.86
d. wound exploration.	63.9	50.0	0.07
e. catheter contrast injection of the wound.	89.2	88.6	0.91
14. In a severely burned patient:
a. the rule of tens is used to assess the body surface area involved.	57.8	88.6	< 0.001
b. associated injuries should be looked for.	72.3	80.7	0.20
c. the body mass should be determined for an accurate fluid therapy.	79.5	92.0	0.02
d. fluid replacement is unnecessary.	97.6	98.9	0.61
e. bacterial infection is easily preventable.	85.5	89.8	0.40
15. In deep burns:
a. full thickness skin grafts are used for treatment.	43.4	30.7	0.09
b. split thickness skin grafts are used for treatment.	26.5	25.0	0.82
c. keloids and hypertrophic scars may develop later.	65.1	77.3	0.08
d. only dressing with germidine lotions and creams are permissible.	86.7	86.4	0.94
e. occlusive dressings should not be done.	83.1	95.5	0.009
16. In the injured hand:
a. direct pressure can be used to control bleeding.	88.0	97.7	0.01
b. elevation of the affected limb can help to control bleeding.	61.4	83.0	0.002
c. direct suturing of the laceration should be done only after 6 hours.	95.2	94.3	1.00
d. the nerves and tendons are not affected.	96.4	97.7	0.67
e. blood supply is always impaired.	83.1	86.4	0.56
17. Lacerations of the hand:
a. require meticulous hemostasis in order to prevent further complications.	65.1	63.6	0.85
b. causing tendon severance should not be managed as emergencies.	74.7	75.0	0.96
c. which are already contaminated need no immediate suturing.	66.3	77.3	0.11
d. as a rule are sutured with absorbable sutures.	91.6	89.8	0.69
e. require no antitetanus therapy.	95.2	92.0	0.40
18. In phallus (penile) injuries:
a. penile fractures should always be surgically managed.	39.8	77.3	< 0.001
b. partial thickness skin grafts are advocated in avulsion injuries.	63.9	71.6	0.28
c. delayed skin grafting is advocated.	66.3	88.6	< 0.001
d. careful repair of tunica albuginea is essential for potency.	37.3	75.0	< 0.001
e. associated ureteric injuries should always be excluded.	30.1	47.7	0.02
19. A forty-year-old farmer was mistakenly shot by a hunter in the village of Atimtim and brought to the hospital. In this patient:
a. no kidney injury is expected if the urine is clear.	74.7	78.4	0.57
b. ureteric injuries cannot occur through gunshot wounds.	96.4	95.5	1.00
c. celiotomy (laparotomy) should be done for genito-urinary injuries only if urine is bloody.	69.9	81.8	0.07
d. If there are no x-rays, urologic injuries cannot be diagnosed.	96.4	97.7	0.67
e. urinalysis may be a useful diagnostic tool in the absence of x-rays.	79.5	92.0	0.02
20. Bladder injuries may be caused by:
a. blunt lower abdominal trauma.	89.2	97.7	0.02
b. fracture of the pelvis.	92.8	98.9	0.06
c. improper instrumentation.	81.9	86.4	0.43
d. gunshot.	88.0	90.9	0.53
e. excessive exercise.	90.4	86.4	0.42
21. In Ghana, urethral trauma is mostly caused by:
a. falling astride.	50.6	80.7	< 0.001
b. gunshot injury.	85.5	85.2	0.95
c. fracture of the pelvis.	68.7	54.5	0.06
d. iatrogenic injuries.	66.3	44.3	0.004
e. coital injuries.	90.4	76.1	0.01
22. Facial wounds following a road traffic accident
a. are never suitable for immediate closure.	84.3	90.9	0.19
b. when involving the scalp are best closed in layers.	24.1	30.7	0.34
c. are best closed with size ‘0’ sutures.	79.5	92.0	0.02
d. may bleed sufficiently to result in shock.	72.3	79.5	0.27
e. may need to be converted into those with straight edges before closure.	48.2	47.7	0.95
23. Suturing technique is different for different parts of the face.
a. The eyelids are closed in a single layer.	21.7	45.5	0.001
b. The ala region of the nose is closed in two layers.	66.3	53.4	0.09
c. The forehead is closed in two layers.	22.9	50.0	< 0.001
d. The ear is closed in three layers.	15.7	54.5	< 0.001
e. The lip is closed in a single layer.	39.8	52.3	< 0.001
24. Concerning open (compound) fractures:
a. they should be toiletted within 6 hours of arrival to the hospital.	74.7	79.5	0.45
b. they should be toiletted within 24 hours of arrival to the hospital.	84.3	90.9	0.19
c. toiletting principally involves rinsing skin over the wound site with antiseptic.	75.9	83.0	0.25
d. toiletting often needs to encompass opening the wound wider and débriding dead tissue.	83.1	93.2	0.04
e. they should not be sutured if there is much contamination.	79.5	87.5	0.16
25. Correct statements regarding skeletal traction include:
a. skin traction is preferable in children.	79.5	84.1	0.44
b. for a femoral shaft fracture, an acceptable weight is 2 kg.	90.4	93.2	0.50
c. for a femoral shaft fracture, an acceptable weight is 10 kg.	43.4	64.8	0.005
d. for a femoral shaft fracture, an acceptable weight is 20 kg.	83.1	90.9	0.13
e. calcaneal traction is a useful technique for femoral shaft fractures.	78.3	78.4	0.99
26. Of the following fractures, indicate as true those two which are most likely to lead to significant deformity and which should be referred to a specialist if possible. Indicate the other three as false.
a. Displaced Colles’ fracture in a four-year-old.	79.5	76.1	0.59
b. Displaced midshaft humerus fracture in a thirty-year-old.	78.3	77.3	0.87
c. Displaced supracondylar fracture of the humerus in a five-year-old.	60.2	64.8	0.54
d. Displaced supracondylar fracture of the femur in a five-year-old.	43.4	55.7	0.11
e. Displaced bimalleolar fracture in a thirty-year-old.	41.0	61.4	0.008
27. At 1 pm you reduce a forearm fracture in a twelve-year-old boy and place a circular POP. At midnight the nurses inform you that his fingers of his hand are cold, swollen, and numb. Appropriate measures to take include:
a. remove the POP.	72.3	72.7	0.95
b. bivalve the POP.	38.6	40.9	0.75
c. raise the hand on a pillow, recheck the circulation in two hours.	57.8	55.7	0.78
d. raise the hand on a pillow, recheck the circulation in the morning.	97.6	94.3	0.44
e. administer antibiotics.	88.0	93.2	0.24
28. Which of the following statements about rib fractures are true?
a. Strapping or taping can help to treat pain and prevent complications.	53.0	67.0	0.06
b. Adequate pain control is necessary to prevent complications.	57.8	75.0	0.02
c. Pneumonia is a likely complication.	62.7	76.1	0.06
d. Narcotic strength pain medications are not often necessary.	80.7	84.1	0.56
e. Rib fractures 9–12 on the left may indicate a splenic injury.	90.4	95.5	0.19
29. The following findings are characteristic of overwhelming post-splenectomy sepsis:
a. shock.	83.1	85.2	0.71
b. hypoglycaemia.	9.6	21.6	0.03
c. disseminated intravascular coagulation.	68.7	71.6	0.68
d. sudden onset of symptoms.	27.7	35.2	0.29
e. headache.	7.2	12.5	0.25
30. You will be shown a series of x-rays. Please indicate which of them shows:
1. tension pneumothorax.	49.4	59.1	0.006
2. small haemothorax with pneumothorax.	51.8	62.5	0.002
3. haemothorax.	18.1	55.7	< 0.001
4. ruptured diaphragm.	16.9	68.2	< 0.001
5. free intra-peritoneal air.	48.2	44.3	0.33