Physiotherapy rehabilitation following severe polytrauma with diffuse axonal injury and multiple upper limb injuries: A case report

C.Sugendhiran1*, A. Ramkumar2, S. Kamalanayagi2, Jamuna Rani2

1Senior physiotherapy, Kauvery Hospital, Hosur, Tamil Nadu

2Physiotherapy, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Background: Severe polytrauma can produce simultaneous neurological, orthopaedic, abdominal and soft-tissue impairments, creating complex rehabilitation priorities. This case describes the physiotherapy assessment and functional progression of a young adult following a road traffic accident complicated by diffuse axonal injury, multiple upper-limb fractures and soft-tissue injuries.

Case presentation: A 22-year-old male worker was admitted following a road traffic accident on 31 -08-2025. The diagnoses RTA included diffuse axonal injury grade II, blunt abdominal injury with jejunal perforation, an open committed right distal humerus fracture with biceps tear, an open left both-bone forearm fracture, left hand crush injury with metacarpal and flexor tendon injuries, chest-wall injury, and additional soft-tissue injuries. Emergency and orthopaedic surgical procedures were performed.

Physiotherapy assessment and management: Initial assessment identified severe functional dependence, pain and swelling of both upper limbs, restrictions related to external fixation and upper-limb immobilization, and inability to fully assess, upper-limb strength and range of motion because of injuries and precautions.  Lower-limb Muscle power was 5/5 at neurological assessment. Functional mobility initially required maximal assistance. Rehabilitation progressed toward standing, ambulation and activities of daily living, with discharge planning including home physiotherapy.

Outcomes: GCS improved from 8/15 at admission to 15/15 by 14-09-2025and remained 15/15 at discharge. At the outpatient assessment, the patient was independent for transfers, standing and walking and modified independent in ADLs. FIM increased from 97/126 on 10-11-2025to 109/126 on 27-02-2026. Upper-limb range of motion and muscle power also improved, although residual postoperative stiffness and right radial nerve palsy with wrist drop noted.

Conclusion: This case demonstrates progressive functional recovery after complex polytrauma through staged, multidisciplinary and injury-specific rehabilitation. Objective measures across neurological, strength, range of-motion and functional domains provide a clinically useful description of recovery.

Key words: Polytrauma; Soft-tissue impairments

Introduction

Poly-trauma is associated with substantial short and long-term disability because several body systems may be affected simultaneously. In addition to survival and surgical stabilization, temporary trauma care increasingly recognizes functional recovery, independence and community reintegration as important outcomes. Recent literature describes acute poly-trauma. Rrehabilitation as a multidisciplinary process that may begin during the acute inpatient phase once medical and surgical stability permits. Diffuse axonal injury is a form of traumatic brain injury associated with impaired consciousness and potentially persistent physical, cognitive and behavioral consequences. Road traffic accidents are an important mechanism of high-energy traumatic brain injury, and recovery may require prolonged multidisciplinary rehabilitation Physiotherapy in severe poly-trauma must balance early restoration of movement and function against fracture stability, surgical precautions, neurological status, pain, wounds and cardiopulmonary tolerance. The available literature supports early, appropriately graded rehabilitation while acknowledging that the exact timing and intensity must be individualized according to injury pattern and medical stability. This case report describes the clinical findings, functional progression and rehabilitation pathway of a young adult with severe polytrauma involving diffuse axonal injury and extensive bilateral upper-limb injuries. The case is clinically relevant because simultaneous neurological and multiple orthopaedic injuries create substantial barriers to early functional independence.

Case presentation

NameMr. xxx
Age / sex22 years / male
OccupationWorker
Mechanism of injury Road traffic accident
Date of admission31 -08-2025
Date of surgery 01 -09-2025
Date of physio assessment05 -09-2025
Date of discharge 22 -09-2025

Chief complaints

  • History of road traffic accident.
  • Loss of consciousness at admission.
  • Difficulty moving both upper limbs.
  • Pain and swelling involving both upper limbs.

History of present illness

The patient was brought to the emergency department following a road traffic accident with multiple injuries. traumatic brain injury, blunt abdominal injury with jejunal perforation, right distal humerus fracture, left both-bone forearm fracture, chest wall injury and left hand crush injury. Emergency surgical procedures done. followed by orthopedic surgery, after which the patient was referred for physiotherapy and further functional management. At discharge on 22 September 2025, at the time of discharge GCS was 15/15 and the ability to ambulate with minimal assistance. The patient was described as functionally modified dependent and was advised home physiotherapy care.

Surgical history

  • Emergency laparotomy with primary closure of jejunal perforation and peritoneal lavage.
  • Wound debridement and suturing (forehead).
  • Wound debridement and external fixation of the right humerus with biceps
  • Open reduction and internal fixation with plating of the left both-bone forearm.
  • Closed reduction/internal fixation with K-wire fixation of the left hand; wound debridement and suturing of the right chest wall (01-09-2025).
  • Bilateral intercostal drain procedure was done on 06-09-2025.

Relevant past history: Status post cleft-lip surgery during childhood.

Medical diagnosis and surgical history

  • Road traffic accident with poly trauma.
  • Diffuse axonal injury, Grade II.
  • Blunt abdominal injury with jejunal perforation.
  • Left Zone 3 flexor injury and left Zone 6 extensor injury.
  • Grade IIIB open comminuted fracture of the right distal humerus with biceps tear.
  • Type I open fracture of the left both-bone forearm.
  • Crush injury of the left hand with fractures of the 2nd, 3rd and 4th metacarpals and     flexor tendon injury.
  • Pancytopenia due to sepsis.
  • Complete fascial dehiscence.
  • Delirium due to general medical condition.

Clinical Examination

Parameter Finding
Body build Ectomorphic
PostureSupine lying
External fixationRight upper limb (humerus)
Other devicesPelvic binder, arm sling for both. Upper limbs, left above-elbow slab

On examination

On palpation

TendernessPresent over both upper limbs and chest region
Muscle spasmPresent over chest region
SwellingPresent
WarmthPresent

Local/regional examination:

  • Right chest wall injury
  •  Right arm: deep laceration over the anterolateral distal one-third, exposing muscle and bone.
  •  Left forearm: deep laceration.
  •  Left hand: dorsal laceration with exposed/cut muscle.
  •  Left iliac / hip region: deep laceration.

Pain assessment

  • Pain intensity: Up to 8/10 during assessment (VAS scale)
  • Site: Bilateral upper limb/chest region
  • Type: Pricking pain
  • Aggravating factors: Patient shifting and movement of both upper limbs
  • Relieving factors: Rest, ice-pack application and medication

Neurological and functional assessment

Glasgow Coma Scale

DateEye openingVerbalMotorTotal GCS
31-08-20252T68/15
05-09-202534613/15
14 -09-202545615/15
22 -09-202545615/15

Functional assessment and physiotherapy goals

Activities

  • Bed mobility
  • Supine to sitting
  • Standing
  • Transfer
  • Ambulation
  • ADLs

Initial status

  • Maximal assistance
  • Maximal assistance
  • Maximal assistance
  • Maximal assistance
  • Maximal assistance
  • Dependent

Goals

Short-term goals

  • Patient education
  • Allow soft tissue healing
  • Reduce pain and edema
  • Prevent pulmonary complication
  • Prevent secondary complication
  • Prevent pressure sores
  • Maintain joint ROM
  • Encourage early mobilization

Long-term goals

  • Independent transfer
  • Improve mobilization
  • Restore upper limb functions
  • Improve muscle strength and endurance
  • Return to activities of daily living

In- patient physiotherapy management

  • Chest physiotherapy and chest vibrator – 4th hourly
  • Passive limb physiotherapy both upper limb and lower limbs.3 times a day
  • Incentive spirometry
  • Passive and Active assisted exercise encouraged both upper limbs
  • Active resisted and strengthening exercise encouraged both lower limbs twice a day
  • Active assisted exercise for both lower limbs
  • Position changing every 2 hours
  • Wheel chair mobilization
  • Sitting balance training
  • Tilt-table standing 30-60 minutes’ ones a day
  • Patient mobilization (walking) maximal support

Inpatient outcomes and transition to outpatient rehabilitation

At discharge on 22-09-2025, GCS was 15/15 and the patient was documented as able to ambulate with minimal assistance. The presentation described the patient as functionally modified dependent and advised home physiotherapy care.

Outpatient physiotherapy assessment

Following hospital discharge, the patient attended the physiotherapy outpatient department for rehabilitation. The presentation states that a comprehensive physiotherapy assessment was performed, current physical and functional status was evaluated, and rehabilitation goals, treatment plan, home exercise programme and necessary precautions were explained to the patient and caregiver.

Clinical findings

  • Postoperative stiffness of both elbows, wrists and fingers.
  • Right radial nerve palsy with wrist drop.
  • External fixation removed on 12-02-2026; POP cast applied to the right arm.

Functional status

Function Outpatient status
TransferIndependent
StandingIndependent
WalkingIndependent
ADLs Modified independent

Outpatient physiotherapy management

  • Active-assisted ROM for both shoulders.
  •  Passive ROM exercises for bilateral upper limbs (shoulder, elbow, wrist and fingers).
  •  Soft-ball gripping exercises for both hands.
  •  Hot fomentation before exercise.
  •  Ice application after exercise when pain or swelling was present.
  •  Functional task-oriented training for both upper limbs.
  •  Progressive strengthening using weight cuffs and resistance band.
  • Wax bath both elbow and wrist join
  • Lower limb &upper limb strengthening exercise
  • Single leg standing
  • Squatting
  • Gait training

Range of motion

JointMovement10-11-202527-02-2026
RLRL
ShoulderFlexion0-90°0-100°0-120°0-160°
Extension0-30°0-40°0-40°0-50°
Abduction0-20°0-50°0¬-90°0-120°
Adduction20-0°50-0°90-0°120-0°
Internal Rotation0-20°0-40°0-60°0-60°
External Rotation0-20°0-40°0-70°0-70°
JointMovement10-11-202527-02-2026
RLRL
ElbowFlexion30-60°20-80°10-90°10-120°
Extension90-60°110-50°110-20°120-10°
Supination0-30°0-20°0-60°0-80°
Pronation0-30°0-20°0-60°0-80°
Supination0-30°0-20°0-60°0-80°
Pronation0-30°0-20°0-60°0-80°
JointMovement10-11-202527-02-2026
RLRL
ElbowFlexion30-60°20-80°10-90°10-120°
Extension90-60°110-50°110-20°120-10°
Supination0-30°0-20°0-60°0-80°
Pronation0-30°0-20°0-60°0-80°
WristFlexion0-30°60-70°0-70°5-20°
Extension0-10°80-50°0-60°60-70°
Ulnar Deviation0-10°0-5°0-20°0-10°
Radial Deviation0-10°0-5°0-20°0-10°
MCPFlexion0-20°0-10°0-50°0-40°
Extension20-0°10-0°50-0°40-0°

Functional Independence Measure (FIM) Outcomes

The outpatient FIM chart documents assessment on 10-11-2025 and 27-02-2026. The total score increased from 97/126 to 109/126, with the final classification marked as modified independence.

Discussion

The case demonstrates a longitudinal transition from critical illness and severe functional dependence to independent basic mobility with residual upper-limb impairment. The initial clinical problem was not a single isolated musculoskeletal injury; rather, the rehabilitation programme had to account for diffuse axonal injury, respiratory compromise, abdominal surgery, multiple open fractures, tendon injuries, chest wall trauma and systemic complications. The highlights the complexity of polytrauma management and the need for a multidisciplinary, phased rehabilitation approach. The inpatient programme appropriately reflected the documented goals of preventing pulmonary and pressure-related complications, maintaining available ROM and initiating progressive mobilization. Chest physiotherapy, breathing exercises, incentive spirometry, positioning, early mobilization (sitting balance, tilt-table standing and assisted walking) and limb exercises were combined with close monitoring of vital parameters and pain control. These interventions likely contributed to improved cardio respiratory function, prevention of secondary complications and readiness for the next phase of rehabilitation. The outpatient phase shifted toward restoration of upper-limb function. Serial ROM measurements showed substantial gains in shoulder and elbow mobility, while the muscle-power chart demonstrated progressive recovery, particularly on the left side. Persistent right radial nerve palsy with wrist drop indicates that neurological and peripheral nerve recovery remained an important rehabilitation problem despite improvements in general mobility. Ongoing strengthening, functional training, splinting and task-oriented therapy are essential for further recovery and compensation. Functional recovery was captured by FIM. The increase from 97/126 to 109/126 was accompanied by a documented change from modified dependence to modified independence. As the patient was already independent in transfers, standing and walking at the first outpatient assessment, later gains were concentrated mainly in self-care and upper-limb-related activities, reflecting meaningful improvements in activities of daily living and participation. The case supports the value of serial, multi domain outcome measurement (e.g., FIM, ROM, muscle power and functional goal) in complex trauma. These measures help to quantify progress, guide treatment modifications and communicate outcomes with the multidisciplinary team, patient and family.

Conclusion

A staged and goal-oriented physiotherapy management accompanied recovery following severe polytrauma with diffuse axonal injury and extensive upper-limb trauma. The patient progressed from severe dependence during the acute hospital phase to independent basic mobility and modified-independent ADLs during outpatient rehabilitation. Serial outcome measures (GCS, ROM, muscle-power and FIM) provide objective evidence of recovery and highlight the importance of coordinated, progressive and individually adapted rehabilitation. effectively addressed prevention of secondary complications, maintenance and restoration of function, and facilitation of participation in daily activities. Persistent right radial nerve palsy with wrist drop indicates ongoing neurological involvement, emphasizing the need for continued upper limb rehabilitation splinting and functional training. this cause underlines the value of a multidisciplinary approach, including medical management. surgical care and contribution from allied rehabilitation disciplines, in achieving meaningful functional outcome in complex trauma. Continued outpatient follow-up is recommended to optimize upper limb function, address residual deficits, support community reintegration and improve overall quality of life. Overall, this cause demonstrates that early, structured and patient-centred rehabilitation can lead to significant functional gains, even in individuals with severe polytrauma and neurological involvement.

Reference

  1. Gagnier JJ, Kienle G, Altman DG, et al. The CARE guidelines: consensus-based clinical case reporting guideline development. J Clin Epidemiol. 2014;67(1):46-51. doi:10.1016/j.jclinepi.2013.08.003.
  2. Riley DS, Barber MS, Kienle GS, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218-235. doi:10.1016/j.jclinepi.2017.04.026.
  3. Klingebiel FKL, Landre V, Hasegawa M, etal. The three stages of polytrauma rehabilitation – a recommendation and a systematic literature review on behalf of SICOT. Int Ortho op. 2025;49(2):365-374. doi:10.1007/s00264-024-06385-0.
  4. Ishaku Z. Evaluating acute polytrauma rehabilitation: a literature review with insights from the UK Major Trauma Network. Cureus. 2025;17(12):e99644. doi:10.7759/cureus.99644.
  5. American College of Surgeons. Best Practices Guidelines: Traumatic Brain Injury. Chicago, IL: American College of Surgeons; verify edition/date against the source used by the authors.

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