Road traffic accident, with tibia fracture

Anusiya M1*, Sonya Mercy Anbu2, Dhariniya S3, Ruby Ravichandran4

1Staff Nurse, ER, Maa Kauvery, Trichy, Tamil Nadu

2Assistant Nursing Superintendent, Maa Kauvery, Trichy, Tamil Nadu

3Nursing Educator, Maa Kauvery, Trichy, Tamil Nadu

4Senior Deputy Nursing Superintendent, Maa Kauvery, Trichy, Tamil Nadu

*Correspondence

Abstract

Tibial fracture is a common long bone injury requiring prompt management. This case study presents a patient with a displaced tibia fracture treated by closed manual reduction. We present a 5-year-old child who presented with pain, swelling and deformity, and diagnosis was confirmed by radiological findings. Closed reduction was performed under sedation, followed by immobilization with a cast. Post procedure alignment was satisfactory, and the patient was monitored for complications with appropriate nursing care and rehabilitation, the patient showed good recovery and functional improvement. The case highlights the effectiveness of closed manual reduction in managing tibia fractures.

Key words: Tibial fracture; Road Traffic Accident (RTA); Pediatric tibia

Introduction

A Road Traffic Accident (RTA) is defined medically as an unexpected incident involving at least one moving vehicle on a public road or path, resulting in injury, fatal or non-fatal, to one or more people. These accidents are a leading cause of traumatic injury and emergency care visits globally. Fracture is a partial or complete break in the continuity of a bone, often involving injury to surrounding soft tissues. Fracture is a partial or complete break in the continuity of a bone, often involving injury to surrounding soft tissues.  Road traffic accidents are a major cause of pediatric trauma and are associated with significant morbidity worldwide. Among long bone injuries, tibia shaft fractures are one of the most common fractures encountered in children because the tibia is a subcutaneous bone and highly vulnerable to direct trauma. Pediatric tibia fractures commonly result from road traffic accidents, falls, or sports injuries and usually present with pain, swelling, deformity, and inability to bear weight. Children may also sustain associated soft tissue injuries, facial trauma, or head injuries, requiring a comprehensive trauma assessment.

Case Presentation

A 5-year-old male child presented with an alleged history of road traffic accident as a pedestrian struck by a two- wheeler. Following the incident, the child sustained injuries to the face, head, and left lower limb. There was no history of loss of consciousness, seizures, vomiting, ear / nose / throat bleeding or abdominal distension. Initial evaluation and first aid management, including suturing of wounds, were performed elsewhere. Upon presentation to the emergency department, the child was conscious, alert, afebrile, and oriented, obeying commands, with normal work of breathing and was hemodynamically stable.

Clinical findings 

On presentation the child’s hemodynamic parameters were within normal limit, with good pulse volume. Vital signs revealed a temperature of 98°F,  Heart rate of 103 beats per minute and oxygen saturation (spo2) was 96% on room air, blood pressure was measured at 120/70 mmHg. Systemic examination was normal.

  • Patient history & immunization status: Child was adequately immunized and intellectual development was normal.
  • Signs & symptoms: The child sustained injuries to the face, head and left lower limbs with associated swelling of the left lower limb. There were sutured wounds over the forehead and chin, multiple abrasions over the right upper limb and lacerations present on the forehead and chin.

Investigations and results

The child’s laboratory investigations revealed a hemoglobin level of 11.3 g/dl and a packed cell volume of 32.9% both within the lower normal range. The red blood cell count decreased slightly to 4.20 million cells/ mm3. A markedly elevated total white blood cell counts of 29.240 cells/ mm3 suggested an ongoing inflammatory or infectious process. The platelet count was 407,000 cells/ mm3, which is mildly elevated.  Coagulation parameters, including prothrombin time of 10.3 seconds, activated partial thromboplastin time of 27.8 seconds, and international normalized ratio of 0.96, were within normal limits. Renal function tests showed a creatinine level of 0.36 mg/dl and urea level of 20 mg/dl both within normal range.  Gram staining of pus demonstrated moderate pus cells with no detected bacteria, and both aerobic and anaerobic cultures showed no growth. Extended focused assessment with sonography for trauma revealed no free fluid, with an incidental finding of mild bilateral hydronephrosis. Chest and pelvis X-rays showed no significant abnormalities. However, X-ray of the left lower limb confirmed a fracture of the shaft of the left tibia. CT brain and face showed no intracranial injury, undisplaced fracture of the left mandibular condyle.

Fig (1): CT Findings

Fig (2): Before POP

Fig (3): After POP

Diagnosis

  • Road traffic accident with soft tissue injury
  • Slicing injury – forehead / chin
  • Shaft of left tibia fracture – reduced
  • Undisplaced left mandibular condyle fracture

Medical management

The child’s treatment plan focuses on a comprehensive regimen of supportive and pharmacological therapies designed to ensure hemodynamic stability and clinical recovery. Hydration and fluid balance were maintained through the administration of intravenous fluids. To address pain and febrile symptoms, parenteral Paracetamol (Inj. Para) was utilized, while broad-spectrum antibiotic coverage was initiated with Augmentin (Inj. Augmentin) to prevent or treat potential infections. Additionally, Chymoral Forte was administered for its anti-inflammatory and anti-edematous properties to reduce swelling, and Essenta D Syrup was provided for supplemental symptomatic relief. Collectively, these interventions aimed to control infection, manage pain, and promote an optimal environment for patient healing.

Surgical management

Child underwent Closed manual reduction under C- arm guidance with Intra venous anesthesia. Traction and counter-traction were applied and the fracture was successfully reduced under fluoroscopic control, following which an above knee slab was applied. Subsequently, soft tissue repair of the forehead and chin was performed under general anesthesia, and pus discharge was noted in the chin region. Thorough wound irrigation was carried out, and the wound edges were trimmed. The forehead laceration was closed with a subcuticular technique and endocryl was applied and chin laceration was sutured. The patient remained hemodynamically stable in the post- procedure period.

Nursing management

The child’s management began with a primary survey to secure the airway, maintain cervical immobilization, and stabilize breathing and circulation through oxygen therapy and fluid resuscitation for shock prevention. Fracture stabilization involved limb elevation, careful positioning, and monitoring cast integrity specifically ensuring a well-molded fit without neurovascular constriction. Pain and wound care were addressed using prescribed analgesics, ice packs, and aseptic dressing techniques, supplemented by antibiotics and tetanus prophylaxis. Finally, recovery was supported through a high-protein, calcium-rich diet and comprehensive patient education on infection signs, cast care, and psychological coping strategies.

Outcome

The child showed satisfactory clinical improvement with proper alignment of the fractured bone confirmed on follow-up imaging. Pain and swelling gradually subsided with immobilization and appropriate medical management. There were no immediate complications such as neurovascular impairment or infection. He was advised strict limb elevation, non-weight bearing initially, and gradual mobilization, with physiotherapy. Over time, he demonstrated progressive healing, improved functional mobility, and was expected to achieve near- normal limb function with continued rehabilitation and follow-up care.

Condition at discharge & follow- up advice

At the time of discharge, the child was clinically stable, afebrile, and adequately hydrated, with satisfactory urine output and stable vital signs. Systemic examination finding was within normal limits. The parents were advised to provide a soft diet as tolerated. Proper care of the plaster of Paris cast was emphasized to ensure immobilization and prevent damage. Limb elevation was recommended to minimize swelling. The child was allowed to maintain a comfortable position, including sitting or lying laterally. Active movements were encouraged to promote circulation and prevent stiffness. Instructions were given to avoid washing the face for three days to promote healing of wounds. Follow-up appointments were scheduled with the plastic surgeon and the orthopedic specialist for further evaluation.

The child was treated with syrup. Augmentin 5ml twice daily after food for 5 days. Syrup. Paracetamol 5 ml three times daily after food for 2 days then SOS, Tablet. Chymoral Forte one tablet twice daily before food for 2 days, and syrup. Essenta D 5 ml once daily after food for 1 month. Parents were advised to report immediately if the child developed high fever, breathing difficulty, persistent cough, vomiting, diarrhea, excessive drowsiness, or reduced urine output.

Conclusion

Early stabilization at a primary center, timely referral and systemic evaluation by neurosurgery, orthopedics, plastic surgery, and maxillofacial teams were crucial in achieving a favorable outcome without complications. This case reinforces the role of multidisciplinary management in pediatric trauma for optimal recovery.

Reference

  1. Mashru, R. P., Herman, M. J., & Pizzutillo, P. D. (2005). Tibial shaft fractures in children and adolescents. Journal of the American Academy of Orthopaedic Surgeons, 13(5), 345–352.

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