Case Study: Multidisciplinary Management of Tibial Shaft Fracture with Intramedullary Nailing

Abstract

This case study describes a 45-year-old male presenting with acute onset severe right lower-leg pain and inability to bear weight after a road traffic accident, diagnosed as a closed transverse fracture of the mid-shaft of the right tibia. The patient underwent closed reduction and intramedullary interlocking nailing within the therapeutic window, followed by early physiotherapy and multidisciplinary rehabilitation. Prompt assessment, timely surgical fixation, and coordinated postoperative care led to complete functional recovery with radiological union at six months. This report emphasizes the importance of rapid stabilization, infection prevention, and integrated rehabilitation in optimizing orthopedic outcomes and minimizing long-term disability.

Introduction

Long bone fractures, particularly tibial shaft fractures, are common and may lead to prolonged disability if not managed promptly and appropriately. Tibial diaphyseal fractures are frequently caused by high-energy trauma such as road traffic collisions. Early and accurate diagnosis, timely stabilization, and a multidisciplinary approach involving orthopedics, anesthesiology, radiology, nursing, and physiotherapy are crucial to restore alignment and function, minimize complications (infection, delayed union, malunion), and accelerate return to activity. This case demonstrates successful outcome after operative fixation with intramedullary nailing and structured rehabilitation.

Patient Information

• Age / Gender: 45-year-old male

• Occupation: Construction supervisor

• Marital Status: Married

• Medical History: Hypertension (6 years, controlled)

• Surgical History: None

• Family History: Non-contributory

• Social History: Occasional smoker, no significant alcohol use, physically active occupation

• Current Medications: Amlodipine 5 mg once daily

• Chief Complaints: Severe right-leg pain, visible deformity, and inability to bear weight following road traffic accident 2 hours prior to presentation

Clinical Findings

Symptoms:

• Severe pain in right mid-leg

• Visible deformity and swelling

• Inability to stand or move the limb

Physical Examination:

• Temperature: 98.4°F

• Pulse: 90 bpm

• Blood Pressure: 138/84 mmHg

• Respiratory rate: 18/min

Local Examination:

• Deformity of mid-right tibia with swelling and tenderness

• Crepitus on gentle manipulation

• No open wound (closed fracture)

• Distal pulses palpable (dorsalis pedis, posterior tibial)

• Sensation intact in foot and toes

Neurovascular Status: Intact

Initial Injury Severity Score / Classification: Closed mid-shaft tibial fracture (transverse) - isolated long-bone injury

Timeline

Initial Presentation (May 2024):
Patient arrived to emergency department within 2 hours of injury. Limb immobilized with an above-knee slab and analgesia started.

Diagnostic Workup (Within 1 Hour):

• Plain radiographs (AP and lateral): transverse mid-shaft fracture of right tibia; fibula intact.

• Routine blood tests: CBC, renal and liver profile, coagulation within normal limits.

• Tetanus status checked.

Therapeutic Decision:

Patient assessed as suitable for operative fixation. Plan: closed reduction and intramedullary interlocking nailing performed within 24 hours. Informed consent obtained.

Treatment (Same Admission):
Closed reduction and intramedullary nailing under spinal anesthesia on Day 2. Prophylactic IV antibiotics administered perioperatively. Tourniquet not required; minimal blood loss.

Postoperative Monitoring:
Transferred to orthopedics ward for monitoring. Neurovascular checks and wound inspection performed regularly. No signs of compartment syndrome or surgical complications.

Early Rehabilitation (Day 2 Post-Op):
Physiotherapy started focusing on quadriceps isometrics, ankle pump exercises, toe movements, and education on non-weight-bearing mobilization with walker.

Discharge (Day 5):
Discharged with oral analgesics, antibiotic course completed, removable splint, physiotherapy plan, and scheduled outpatient follow-up.

Follow-Up (3 Months Later):
Progressive clinical improvement; partial weight-bearing initiated with walking aid. Radiographs showing progressive callus formation.

Diagnostic Assessment

Laboratory Findings:

• CBC, RFT, LFT: within normal limits

• Hb: 13.4 g/dL

• ESR: 20 mm/hr

• CRP: 9 mg/L (mild post-traumatic elevation)

Imaging Findings:

• Preoperative X-ray: Transverse mid-shaft fracture of right tibia.

• Immediate Postoperative X-ray: Acceptable alignment with intramedullary interlocking nail and interlocking screws in situ.

• 3-month Follow-up X-ray: Bridging callus at fracture site.

• 6-month Follow-up X-ray: Radiological union with cortical continuity.

Risk Evaluation:

• Etiology: High-energy trauma (road traffic accident).

• ASA Classification: Class II.

• Infection Risk: Low (closed fracture, timely perioperative antibiotics).

• Thromboembolic Risk: Moderate (reduced mobility initially).

• Complication Risk: Delayed union risk increased by smoking history (occasional).

Therapeutic Intervention

Step 1 – Emergency and Preoperative Management

• Rapid trauma assessment, immobilization with above-knee slab.

• Analgesia (IV paracetamol ± opioid), IV access and baseline investigations.

• Tetanus prophylaxis as indicated.

• Preanesthetic evaluation and consent for surgery.

Step 2 – Surgical Fixation

• Closed reduction under fluoroscopic control.

• Intramedullary interlocking nailing with appropriately sized reamed nail.

• Intraoperative fluoroscopy confirmed alignment and screw placement.

• Perioperative IV antibiotic prophylaxis (cefuroxime) and thromboprophylaxis as per hospital protocol.

Step 3 – Postoperative and Rehabilitation

• Early physiotherapy: quadriceps sets, knee/ankle ROM, pulmonary exercises.

• Limb elevation, cryotherapy for swelling.

• Non-weight-bearing ambulation with walker for initial 6 weeks.

• Gradual progression to partial weight-bearing at 6–8 weeks dependent on radiographic healing; full weight-bearing by 12 weeks if adequate callus.

• Wound care with suture removal at 10–14 days and regular outpatient radiographs.

Challenges Faced

• Pain Control: Required multimodal analgesia in immediate postoperative period.

• Swelling Management: Local edema interfered with early ROM — managed with elevation and compressive dressings.

• Smoking History: Patient counseled on cessation to optimize bone healing.

• Rehabilitation Adherence: Ensured via physiotherapy sessions, written home exercise program, and telephonic follow-up.

Follow-Up and Outcomes

• 1 Week: Wound inspection; sutures intact; pain decreasing.

• 1 Month: Improved ROM at knee and ankle; non-weight-bearing maintained.

• 3 Months: Partial weight-bearing initiated; radiograph with callus formation; walking with cane.

• 6 Months: Full radiological union; pain-free; independent ambulation without aids; resumed work duties with gradual return to heavy activity deferred per surgeon advice.

Discussion

This case demonstrates that timely operative stabilization with intramedullary nailing combined with early, structured multidisciplinary rehabilitation produces excellent functional outcomes for tibial shaft fractures. Intramedullary nailing provides stable fixation allowing controlled early mobilization, which mitigates stiffness and muscle atrophy. Close perioperative management including infection prophylaxis, thromboprophylaxis, and smoking cessation counseling - contributed to uncomplicated healing. Regular radiographic monitoring guided progressive weight-bearing. Multidisciplinary coordination among orthopedics, anesthesia, physiotherapy, and nursing optimized recovery and patient satisfaction. Evidence supports intramedullary nailing as the standard of care for diaphyseal tibial fractures, with better functional outcomes and lower reoperation rates compared with some alternative methods when indicated.

Key Takeaways

• Prompt recognition and timely surgical stabilization are essential for optimal tibial fracture healing.

• Intramedullary interlocking nailing provides mechanical stability and facilitates early rehabilitation.

• Multidisciplinary care (surgery + physiotherapy + nursing + patient education) accelerates recovery.

• Control of modifiable risk factors (smoking, glycemic control, nutrition) improves bone healing.

• Scheduled radiological follow-up is necessary to tailor weight-bearing progression.

Patient’s Perspective

“I was frightened I might not walk properly after the accident. The team explained every step clearly. Surgery went well and physiotherapy pushed me gently but steadily. Now, months later, I walk and work normally. I’m grateful for the quick and coordinated care that helped me recover.”

Conclusion

This case underscores that integrating timely operative fixation with early, coordinated rehabilitation offers the best outcomes for tibial shaft fractures. Success depended on accurate assessment, prompt surgery, perioperative vigilance, and patient-centered rehabilitation. Multidisciplinary frameworks, patient education, and adherence to evidence-based protocols reduce complications, speed recovery, and restore function.

A structured, stepwise approach beginning at the emergency department is vital for ensuring a smooth continuum of care. The decision to perform intramedullary nailing within the first 24 hours minimized risks of soft-tissue contracture, alignment loss, and infection, while allowing early initiation of physiotherapy. This aligns with current orthopedic trauma guidelines advocating early stabilization of long-bone fractures whenever hemodynamic conditions permit. Close intraoperative attention to mechanical alignment, reaming technique, and locking screw placement ensured biomechanical stability, facilitating progressive mobilization.

Equally important was the postoperative phase, where physiotherapy played a transformative role in regaining muscle strength, joint mobility, and balance. Early movement prevented stiffness and venous stasis, reducing thromboembolic risk. Regular follow-ups, radiographic assessments, and tele-rehabilitation sessions reinforced compliance with exercise and lifestyle modifications. Nutritional counseling with adequate protein and vitamin D intake supported bone remodeling.

Overall, this case exemplifies the synergy between surgical precision and rehabilitative science. By integrating orthopedic expertise with physiotherapy, nursing care, and patient education, the team achieved full functional recovery without complications. This comprehensive, patient-centric approach demonstrates how evidence-based multidisciplinary collaboration transforms a potential long-term disability into a successful restoration of independence and quality of life.

References

1. Court-Brown CM, McQueen MM. The Epidemiology of Tibial Fractures. Bone Joint J. (2012).

2. Bhandari M, et al. Intramedullary Nailing Versus Plating in Tibial Shaft Fractures. J Orthop Trauma. (2001).

3. Brumback RJ, et al. Functional Outcomes of Tibial Shaft Fractures Treated with Intramedullary Nailing. J Bone Joint Surg Am. (1997).

4. Gustilo RB, Anderson JT. Prevention of Infection in Open Fractures of Long Bones. Clin Orthop Relat Res. (1984).

5. NICE (2023). Fractures (Complex): Assessment and Management.

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