Multidisciplinary management of a complex proximal Tibia fracture with vascular injury

Multidisciplinary management of a complex proximal tibia fracture with vascular injury

Subin*

ICU Supervisor, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Road traffic accident is a major cause of polytrauma and musculoskeletal injuries worldwide. This case highlights of the importance of early diagnosis, vascular assessment, and prompt surgical intervention in complex lower limb fractures associated with vascular injury to prevent complications and improve functional outcome.

Key words: Road traffic accident; Proximal tibia

Introduction

Road traffic accidents are one of the leading causes of morbidity and mortality globally. They often result in multiple injuries, involving bones, soft tissues and neurovascular structures. Fracture around the knee, especially proximal tibia fracture, are complex injuries that can be associated with significant soft tissue damage and vascular compromise.

The proximal tibia is prone to communicated fracture from high energy trauma encountered in motor vehicle accidents. When associated with anterior tibial artery injury, it becomes a surgical emergency as delayed revascularization can lead to limb threatening condition like compartment syndrome, ischemia and poor functional outcomes.

This case report discusses the management of patient with a left proximal tibia closed comminute fracture with associated anterior tibial artery injury and right distal radius fracture following RTA, managed with open reduction internal fixation, vascular repair, and splinting.

History of present illness

A 56-year-old male was brought to the Emergency Department with an alleged history of a road traffic accident (RTA) on 15/06/2026 at around 10:00 PM near Nallur.

He was travelling as a back-seat passenger in a four-wheeler when the vehicle reportedly lost control and collided with a stone. Following the accident, he sustained injuries to the head, left knee and right wrist and complained of pain over the injured sites.

The patient was initially treated at an outside Hospital and was subsequently referred to the present hospital for further evaluation and management.

Past medical history

Known case of hypertension – On regular antihypertensive medication.

Diagnosis

Left Proximal Tibia closed comminute fracture (Posterior Lateral)

Left anterior Tibial artery injury

Closed Un-displaced distal radius fracture right wrist

Investigations

Investigation	Result
Hb	13.4 g/dl
Hematocrit	40.4 %
Total WBC Count	8350 cells/cumm
Platelet Count	201000 Lakhs/ Cumm
Urea	21.4 mg/dl
Creatinine	1.0 mg/dl
Sodium	136 mmol/L
Potassium	4.1 mmol/L
pH	7.36
PCO2	45 mmHg
PO2	70 mmHg
HCO3	25.4 mmol/L

X-ray

Case Presentation

A 56-year-old male sustained multiple injuries following a road traffic accident (RTA). He received initial treatment at an outside hospital and was subsequently referred to our hospital for definitive management.

On admission, the patient was hemodynamically stable, with vital signs within normal limits. Local examination revealed swelling and redness over the left knee and left wrist. Radiological evaluation, including X-ray examination, revealed a fracture involving the left proximal tibia. Clinical assessment also showed reduced distal blood flow in the affected lower limb, raising suspicion of an associated vascular injury.

Following further clinical and radiological evaluation, the patient was diagnosed with a closed comminuted fracture of the left proximal tibia with associated left anterior tibial artery injury.

Intraoperative management

After obtaining informed written consent, the patient underwent Open Reduction and Internal Fixation (ORIF) of the left proximal tibia with posterior plating under general anesthesia. During the procedure, an anterior tibial artery tear was identified. The Cardiothoracic and Vascular Surgery (CTVS) surgeon was consulted intraoperatively, and vascular repair of the injured artery was successfully performed.

Following fixation and vascular repair, the surgical site was assessed for hemostasis and distal limb perfusion. The operative wound was appropriately managed and dressed.

A below-elbow splint was applied to the right upper limb, providing posterolateral and anterolateral support as documented. The patient was subsequently transferred to the postoperative care area for continued monitoring of hemodynamic status, distal circulation, neurological function, and postoperative complications.

Postoperative Management

Following surgery, the patient remained hemodynamically stable with satisfactory postoperative recovery. Serial monitoring of vital signs, oxygen saturation, wound condition, pain, swelling, and distal neurovascular status was continued. Follow-up X-ray demonstrated good fracture reduction and satisfactory alignment, with palpable distal pulses indicating satisfactory peripheral perfusion.

POD 1 – The postoperative dressing was intact with no soakage or evidence of active bleeding. A cardiology opinion was obtained in view of the patient’s pre-existing medical condition. CTVS consultation was also obtained for postoperative vascular monitoring. Antiplatelet therapy was continued as prescribed, with ongoing assessment of distal limb perfusion.

POD 2 – The surgical dressing was changed and the wound was appropriately cleaned and assessed. The patient was provided with walker support for mobilization as advised. Distal pulses remained palpable, indicating maintained peripheral circulation. Oxygen saturation was maintained at 96%.

POD 3 – The patient showed reduction in pain and swelling of the affected limb. Regular physiotherapy was continued. The patient was mobilized with a walker, with weight-bearing on the affected limb restricted or permitted according to the orthopedic team’s advice.

POD 4 – The surgical drain was removed, followed by dressing and wound cleaning. The wound remained satisfactory without significant complications. The patient continued to receive prescribed antibiotics, analgesics, antiemetics, antihypertensive, antiplatelet therapy, and other supportive medications. Ongoing neurovascular monitoring, wound care, physiotherapy, and mobilization were continued.

Nursing management

1. Neurovascular Monitoring

The patient’s neurovascular status was monitored regularly. Distal pulse, skin colour, temperature, and capillary refill were assessed hourly during the first 24 hours following surgery. Any changes in circulation, sensation, or limb perfusion were promptly identified and immediately reported to the treating team.

2. Wound Care

The surgical wound and dressing were monitored regularly for bleeding, soakage, swelling, discharge, and signs of infection. Any excessive bleeding or abnormal wound findings were promptly reported and appropriate wound care was provided.

3. Limb Positioning

The affected limb was elevated on pillows as advised to reduce postoperative swelling and promote venous return. The limb position was maintained appropriately while ensuring that circulation was not compromised.

4. Monitoring for compartment syndrome

The patient was closely observed for increasing or severe pain, tense swelling, altered sensation, changes in skin colour, and reduced distal circulation, which could indicate compartment syndrome. Any suspicious findings were immediately communicated to the medical team for further evaluation and management.

5. Nutritional Management

The patient was encouraged to consume a high-protein and calcium-rich diet to support tissue repair, bone healing, and postoperative recovery. Adequate fluid and nutritional intake were also encouraged as tolerated.

6. Medication Management

Prescribed medications, including analgesics, antibiotics, antiplatelet therapy, antihypertensive, and other supportive medications, were administered as ordered. The patient was monitored for therapeutic response and any adverse effects.

7. Physiotherapy and Mobilization

The patient received physiotherapy as advised by the treating team. Mobilization was initiated progressively using a walker, with weight-bearing restrictions followed according to the orthopaedic team’s recommendations.

8. Discharge Health Education

Before discharge, the patient and caregivers were educated regarding wound care, prescribed medications, exercises, limb care, activity and weight-bearing restrictions, and follow-up appointments. They were also instructed to seek immediate medical attention if they noticed increasing redness, swelling, wound discharge, numbness, severe pain, reduced limb circulation, chest pain, or difficulty in breathing.

Outcome

The patient demonstrated a satisfactory postoperative recovery following fracture fixation and anterior tibial artery repair. He remained hemodynamically stable throughout the postoperative period, with palpable distal peripheral pulses and satisfactory distal limb perfusion. Follow-up radiography showed good fracture reduction and satisfactory alignment. The patient experienced a progressive reduction in pain and swelling, and the surgical wound remained clean and satisfactory without significant postoperative complications. The surgical drain was successfully removed on postoperative day 4. Physiotherapy was continued, and the patient gradually progressed with walker-assisted mobilization while adhering to the prescribed weight-bearing restrictions. Active toe movements were present, indicating preserved distal motor function. Overall, the patient showed favorable early clinical progress following combined orthopedic fixation and vascular repair.

Condition at Discharge

At the time of discharge, the patient was conscious, oriented, and hemodynamically stable, with satisfactory distal circulation and preserved active toe movements. He was using the prescribed knee brace and was mobilizing with walker support under non-weight-bearing (NWB) precautions as advised by the orthopedic team. He was discharged with appropriate postoperative medications, rehabilitation instructions, and follow-up recommendations. The patient and caregivers were educated regarding wound care, medication adherence, prescribed exercises, limb care, weight-bearing restrictions, and scheduled follow-up visits. They were also advised to seek immediate medical attention in the event of increasing pain or swelling, redness, wound discharge, numbness, reduced limb circulation, chest pain, or difficulty in breathing.

Discussion – Medical aspects

Proximal tibial fractures following high-energy trauma can be complex because of associated soft-tissue, neurological, and vascular injuries. The presence of an arterial injury significantly increases the risk of limb-threatening complications. Therefore, early recognition of vascular compromise and repeated neurovascular assessment are essential components of management.

In this case, reduced distal blood flow in the affected lower limb prompted further evaluation and appropriate vascular assessment. During surgery, an anterior tibial artery tear was identified, and CTVS assistance was obtained for vascular repair. Simultaneous management of the fracture and vascular injury helped restore and maintain distal limb perfusion.

ORIF with posterior plating provided stabilization of the proximal tibial fracture and helped achieve satisfactory alignment. Postoperative radiography confirmed good reduction and alignment. The presence of palpable distal pulses following vascular repair indicated satisfactory peripheral perfusion.

Close postoperative surveillance was important because patients with vascular injury and high-energy fractures remain at risk for complications such as vascular occlusion, compartment syndrome, and infection, wound complications, and impaired fracture healing. In this patient, serial neurovascular assessment, antiplatelet therapy, wound monitoring, physiotherapy, and progressive mobilization contributed to a satisfactory early postoperative outcome.

Discussion – Nursing aspects

Nursing care played an important role in the patient’s recovery following complex orthopedic and vascular surgery. Frequent neurovascular assessment was particularly important because early changes in pulse, skin colour, temperature, capillary refill, sensation, or movement could indicate vascular compromise or compartment syndrome.

Postoperative nursing care focused on maintaining adequate circulation, monitoring the surgical wound, controlling pain, administering prescribed medications, supporting limb positioning, and preventing complications. The surgical wound was regularly assessed for bleeding, soakage, swelling, discharge, and infection.

Nurses also contributed significantly to safe mobilization and rehabilitation. Walker-assisted mobilization was provided according to the prescribed weight-bearing restrictions, and physiotherapy was continued to promote functional recovery.

Nutritional education regarding adequate protein and calcium intake supported tissue and bone healing. At discharge, patient and caregiver education focused on medication adherence, wound care, exercises, activity restrictions, recognition of warning signs, and follow-up care.

The case emphasizes the importance of multidisciplinary collaboration among orthopaedic surgeons, CTVS surgeons, physicians, cardiology specialists, nurses, physiotherapists, and the patient’s caregivers in achieving a favourable outcome in complex trauma cases.

Conclusion

This case demonstrates the importance of early diagnosis, comprehensive neurovascular assessment, timely vascular consultation, and appropriate surgical intervention in managing proximal tibial fractures associated with arterial injury following high-energy trauma.

Successful fracture fixation combined with vascular repair restored satisfactory limb perfusion and provided mechanical stability. Consistent postoperative neurovascular monitoring, wound care, medication management, physiotherapy, nutritional support, and patient education contributed to the patient’s progressive recovery.

A coordinated multidisciplinary medical and nursing approach is essential to prevent limb-threatening complications, promote fracture and wound healing, facilitate safe mobilization, and improve functional outcomes in patients with complex orthopaedic injuries associated with vascular compromise.

Multidisciplinary management of a complex proximal Tibia fracture with vascular injury