A case of polytrauma following road traffic accident with small bowel gangrene

Christine Rajathi1*, Subathra Devi. M2, Maha Lakshmi3

1Nursing Supervisor, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

2Nurse Educator, Kauvery Hospital. Cantonment, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence

Abstract

Polytrauma secondary to Road Traffic Accidents (RTAs) constitutes a major surgical and nursing challenge. Cases with concurrent orthopedic fractures, abdominal injury, and vascular compromise require extensive, coordinated care.

Key words: Polytrauma; Road Traffic Accidents (RTAs)

Introduction

Road Traffic Accidents (RTAs) remain one of the leading causes of polytrauma worldwide, often resulting in life-threatening, multi-system injuries that demand rapid, coordinated medical and nursing intervention. Polytrauma is defined as the simultaneous injury of multiple body regions or organ systems, at least one of which is life-threatening. The complexity of such cases challenges every member of the healthcare team, with nurses at the forefront of continuous assessment, monitoring, and holistic patient care. The study aims to highlight the pivotal role of nurses in the comprehensive rehabilitation and recovery of a polytrauma patient.

Case Presentation

A 43-year-old male was admitted on 05/05/2026 following an alleged RTA at 03:30 AM. He presented with an open Grade III B multi fragmentary distal femur fracture with intra-articular involvement (left), closed distal tibia pilon fracture (left ankle), bilateral pubic rami fracture (left), both bone forearm fracture (left), transverse process fractures (L2–L5), 2nd and 10th rib fractures with minimal pleural effusion, left scapula fracture, umbilical hernia, multi-ligamentary injury (ACL, MCL, LCL) of the left knee, and blunt abdominal injury with small bowel gangrene and perforation totaling 10 distinct diagnoses.

The patient presented the following complaints:

  • Severe pain and deformity of the left lower limb
  • Swelling and open wound over the left knee (previously sutured at referring hospital),
  • Swelling and tenderness over the left forearm with distal pulse intact
  • Bilateral rib tenderness
  • Pelvic tenderness
  • Mild tenderness over the left shoulder region
  • Diffuse abdominal tenderness

Relevant Clinical Findings

Social History

  • Allergies: No known drug allergies
  • Past Medical History: Nil
  • Past Surgical History: Nil

Relevant Investigation

Multislice CT scan chest (Plain Study) | 04.05.2026

No evidence of hemopneumothorax at present

  • Minimal left pleural effusion with collapse of left lower lobe, right basal atelectasis, Left Lower Limb – Arterial Doppler Study | 04.05.2026
  • Post-traumatic occlusion of the left upper 2/3rd of the posterior tibial artery (PTA)
  • CT lower limb angiogram advised for further evaluation

Multislice CECT Abdomen and Pelvis | 05.05.2026

  • Fracture of transverse process of L2, L3, L4, and L5 vertebrae on both sides with fracture fragments and adjacent hematoma
  • Fracture of sacrum, superior and inferior pubic rami on left side with fracture fragments, adjacent hematoma, and free fluid in the pelvis and retroperitoneum
  • Bilateral renal simple cysts
  • Umbilical hernia identified

Multislice CT Scan – Chest (Plain Study) | 05.05.2026

  • Bilateral mild pleural effusion
  • Posterobasal atelectasis in bilateral lobes
  • Diffuse ground-glass density in bilateral lung fields
  • Fracture of left scapula and 1st and 10th ribs on left side

Left Lower Limb – Venous Study 06.05.2026

  • No evidence of deep venous thrombosis (DVT) in the left lower limb

Multislice CECT Abdomen and Pelvis | 12.05.2026 (Repeat)

  • Large ill-defined hypo dense collection with multiple air pockets in right side of abdomen extending from sub hepatic region to pelvis, thickened mesentery noted with mild pneumoperitoneum.
  • Possibility of mesenteric and bowel injury considered possibility of partial small bowel obstruction.
  • Dilated small bowel loops with transition point in distal ileum.
  • Grade I injury in right lobe of liver.
  • Bilateral simple renal cortical cysts
  • Displaced fractures of transverse process L2–L5, sacrum, and superior and inferior pubic rami on left side

Abdomen Scan – Bedside Ultrasound | 26.05.2026

  • Hepatomegaly with Grade I fatty change
  • Echogenic sludge in gallbladder
  • Borderline splenomegaly
  • Right renal cortical cyst
  • Minimal free fluid in subhepatic space

Diagnosis

  • Open Grade III B Multifragmentary Distal Femur Fracture with Intraarticular Involvement – Left
  • Closed Distal Tibia Pilon Fracture – Left Ankle
  • Superior and Inferior Pubic Rami Fracture – Left
  • Both Bone Forearm Fracture – Left
  • Transverse Process Fracture L2–L5
  •  2nd and 10th Rib Fracture with Minimal Pleural Effusion
  • Scapula Fracture – Left
  • Umbilical Hernia
  • Multi ligamentary Injury (ACL, MCL, LCL) – Left Knee
  • Blunt Injury Abdomen – Small Bowel Gangrene with Perforation

Surgical Management

This patient required four staged surgical procedures over the course of his hospitalization, performed under the leadership of Dr. Ramasamy P R (MS Ortho, FRCS) and a large multidisciplinary surgical team.

Surgery I – 06.05.2026 (Under General Anesthesia)

  • Wound Debridement + ORIF with Distal Femur Plating and Cerclage Wiring – Left.
  • ORIF Distal Tibia Plating + K-Wire Fixation of Medial Malleolus – Left.
  • CRIF with K-Wire Fixation of Fibula – Left.

This first surgery addressed the most immediate life- and limb-threatening orthopedic injuries. The open femur fracture was debrided to reduce infection risk and fixed with a locking compression plate and cerclage wires. The tibia pilon fracture was fixed with a distal tibia medial plate. The fibula was managed with a closed reduction and K-wire fixation.

Surgery II – 08.05.2026 (Under Nerve Block Anaesthesia)

  • ORIF with Radius Plating and TENS Nailing for Ulnar Fracture – Left Forearm
  • The both-bone forearm fracture was managed with open reduction and internal fixation using a radius plate and titanium elastic nail (TENS nail) for the ulna, under nerve block anaesthesia.

Surgery III – 13.05.2026 (Under General Anaesthesia) — Emergency Laparotomy

  • Laparotomy, Terminal Ileal Resection, and Double Barrel Stoma.

 

Surgery IV – 25.05.2026 (Under General Anaesthesia)

  • Wound Debridement with Antibiotic Cementing – Left Femur.
  • TENS Nail Removal and Plate Osteosynthesis – Left Ulna.
  • This fourth procedure addressed residual wound infection at the femur site with antibiotic cement application and upgraded the ulnar fixation from TENS nail to plate osteosynthesis for superior stability.

Outcome

After 28 days of inpatient care, the patient was discharged in stable condition with vitals stable, transferred to outside Hospital, Alwarpet (Chennai) for further rehabilitation.

Nursing Management

Pre-operative Nursing Care

  • Rapid primary and secondary survey on admission using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).
  • Establishment of two large-bore IV access lines and commencement of IV fluids.
  • Continuous monitoring of vital signs — PR, BP, SpO2, temperature, and GCS.
  • Cardiac monitoring for haemodynamic instability.
  • Positioning: Supine with limb elevation to reduce oedema and venous stasis.
  • Wound assessment: Open wound over left knee assessed for contamination, bleeding, and neurovascular integrity.
  • Neurovascular checks of all injured limbs — pulse, capillary refill, sensation, and movement (every 1–2 hourly).
  • Pain assessment using Numeric Pain Rating Scale (NRS); administration of IV analgesics as prescribed.
  • Catheterization for urinary output monitoring (target: >0.5 mL/kg/hour).
  • Blood and urine samples collected for baseline investigations (CBC, RFT, LFT, coagulation profile, blood grouping and crossmatching).
  • Pre-operative education provided to patient and family about planned procedures, ICU care, and expected recovery.
  • Informed consent facilitated and documented.

Post-operative Nursing Care 

  • Post-operative vital signs monitoring every 15–30 minutes, progressing to hourly as patient stabilized.
  • GCS monitoring with neurological assessments (noting any deterioration)
  • Fluid balance: Strict hourly intake-output charting; electrolyte replacement (IV Potassium Chloride infusion as needed).
  • Skin care: Regular repositioning (2-hourly); pressure area care.
  • DVT prophylaxis: Subcutaneous Clexane (Enoxaparin) administered; anti-embolic stockings applied to uninjured limb.
  • Nutritional support: Nasogastric tube feeding or parenteral nutrition until bowel function returns; dietician referral post-laparotomy.
  • Physiotherapy: Passive limb movements, chest physiotherapy, spirometry exercises commenced early.
  • Psychological support: Regular communication with patient (when conscious) and family regarding progress, addressing anxiety and fear.

Stoma Care 

  • Color (should be pink/red and moist), size, protrusion, and surrounding skin condition assessed at every shift.
  • Appropriate stoma bag fitted and changed as needed; adhesive skin barrier applied to protect peristomal skin.
  • Cleaning with warm water, drying thoroughly, and application of barrier cream to prevent excoriation from digestive enzymes.

Infection Prevention and Control 

  • Strict hand hygiene (5 moments) by all healthcare providers.
  • Aseptic non-touch technique (ANTT) for all wound dressings, IV line care, and catheter care.
  • Isolation precautions if MDR organisms detected on culture.
  • Antibiotic administration on time as prescribed; monitoring for allergy and adverse reactions.

Pain Management 

  • Pain reassessment using NRS scale every 4 hours and after analgesic administration
  • Non-pharmacological measures: Comfortable positioning, limb elevation, ice packs (if appropriate), distraction, relaxation techniques
  • Documentation of pain scores and analgesic efficacy

Discharge medications

Drug NameStrengthRouteFrequencyMeal RelationDuration
Cap. Laribone-Oral1-0-0After Food1 Month
Tab. Pan40mgOral1-0-1Before Food7 Days
Tab. Trika0.5mgOral0-0-1After Food7 Days
Tab. Ultracet100mgOral1-0-1After Food7 Days
Tab. Ecosprin150mgOral0-1-0After FoodTill Review
Tab. Doxy100mgOral1-0-1After FoodTill Review

Orthopaedic Advice on Discharge

  • Bed rest
  • Active toe movements
  • Spirometry exercises
  • Review on 16.06.2026 at 11:00 AM in Ortho OPD

Surgical Gastroenterology Advice on Discharge

  • Daily wound wash and dressing
  • Stoma care (daily)
  • Review on 16.06.2026 in Dr. S. Velmurugan’s OPD

Discussion  

This case shows how a serious road accident can affect a person’s whole body and need a lot of care. Even though the patient was healthy before, he needed multiple surgeries and stayed in the hospital for almost a month. The main reason he recovered well was quick treatment, good teamwork between doctors and nurses, and proper care after surgery. It shows that in major accidents, early treatment, close monitoring, and planning for recovery are very important. Nursing care also plays a big role in helping the patient heal and get back to normal life. 

Conclusion

This case of severe polytrauma in a 43-year-old male following a Road Traffic Accident illustrates the extraordinary complexity that nurses may encounter in acute and surgical care settings. With ten simultaneous diagnoses, four major surgeries, 28 days of hospitalization, and involvement of eight medical specialties, this case demanded exceptional clinical judgement, technical skill, and compassionate care from every nurse involved. Nursing management extended across trauma assessment, pre-operative preparation, multi-site wound care, ICU monitoring, stoma care, DVT prophylaxis, respiratory support, nutritional management, pain control, and comprehensive discharge education. Each dimension required specialized knowledge and careful, evidence-based practice.

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