Risk Factors for Delayed Presentation Among Patients with Musculoskeletal Injuries in Malawi

Epidemiology and Management of Pediatric Fractures in Malawi

BACKGROUND

Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development.

METHODS

We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment.

RESULTS

From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77).

CONCLUSIONS

Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi.

Differential screen and treatment of sternocleidomastoid syndrome versus eagle syndrome: a case report

BACKGROUND/PURPOSE

Differential screening is a complex process in chronic pain conditions. There is significant uncertainty that surrounds the pathophysiology of many chronic pain syndromes that may lead to misdiagnosis and treatment failures. Such differential screening is even more challenging where there is regional overlapping from surrounding tissues. This case report chronicles the differential screening and treatment of a patient with sternocleidomastoid syndrome (SCMS) originally diagnosed as Eagle's syndrome (ES).

CASE DESCRIPTION

A 55-year-old woman, referred to a physical therapist (PT) by an ear, nose and throat (ENT) physician with the diagnosis of ES. The patient complained of yearlong left-sided otalgia, blurred vision, excessive lacrimation, dysphagia, hyperesthesia on the left side of the face, unilateral temporal headaches, and both left mandibular and anterior neck pain.

OUTCOMES

The PT examination revealed the patient did not exhibit hallmark findings for clinical confirmation of ES and instead demonstrated multiple signs consistent with SCMS.

DISCUSSION

Manual therapy techniques and therapeutic exercises resolved the patient's year-long chronic symptoms within 6 sessions.

Epidemiology and Treatment of Distal Radius Fractures at Four Public Hospitals in Malawi

BACKGROUND

Little is known about the burden or management of distal radius fractures (DRFs) in low- and middle-income countries. The purpose of this study was to describe the care of DRFs in Malawi.

METHODS

We retrospectively reviewed a registry of all patients with fractures who presented to the orthopaedic departments at four public hospitals in Malawi.

RESULTS

Totally, 1,440 patients (14.5%) were with a DRF. Average age was 40, and 888 (62.0%) were male. Surgery was done for 122 patients (9.5%). Patients presenting to Queen Elizabeth Hospital, patients presenting after a fall, and patients initially evaluated by an orthopaedic registrar or orthopaedic clinical officer had lower odds of receiving surgical treatment. Meanwhile, open injuries had the greatest odds of receiving surgery.

CONCLUSION

The most common musculoskeletal injury among patients in the Malawi Fracture Registry was fractures of the distal radius. These most affected young adult male patients may benefit from surgery; however, the majority were managed nonsurgically. Lack of access to surgical fixation and conservative follow-up may have long-term functional consequences in a predominantly agrarian society. Outcomes-based research is needed to help guide management decisions and standardize patient care and referral protocols.

The burden of long bone fracture and health system response in Malawi: A scoping review

OBJECTIVES

Fractures pose serious health and socioeconomic consequences for individuals, their families, and societies more broadly. In many low-resource settings, case fatality and long-term sequelae after a fracture remain high due to individual- and system-level barriers affecting timely access to care. This scoping review explored the burden of fractures in Malawi using long bone fracture (LBF) as a case study by examining the epidemiology of these injuries, their consequences, and the accessibility of quality healthcare. Our aim is to not only describe the scale of the issue but to identify specific interventions that can help address the challenges faced in settings with limited resources and healthcare budgets.

METHODS

A scoping review methodology was adopted with a narrative synthesis of results. We searched five databases to identify relevant literature and applied the "Three Delays" model and the WHO's Building Blocks Framework to analyse findings on the accessibility of fracture care.

RESULTS

Fractures most often occurred among young males, with falls being the leading cause, constituting between 5 and 35 % of the total burden of injuries. Fractures were typically managed without surgery despite consistent local evidence showing surgical treatment was superior to conservative management in terms of length of hospital stay and bone healing. Poor functional, economic, and social outcomes were noted in fracture patients, especially after conservative treatment. A lack of trust in the health system, financial barriers, poor transport, and road infrastructure, and interfacility transfers were identified as barriers to care-seeking. Factors challenging the provision of appropriate care included governance issues, poor health infrastructure, financial constraints, and shortage of supplies and human resources.

CONCLUSIONS

To the best of our knowledge, this review represents the first comprehensive examination of the state of LBF and the health system's response in Malawi. The findings underscore the pressing need for a national trauma registry to accurately determine the actual burden of injuries and support a tailored approach to fracture care in Malawi. It is further evident that the health system in Malawi must be strengthen across all six building blocks to address obstacles to equitable access to high-quality fracture care.

Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi

BACKGROUND

Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings.

METHODS AND FINDINGS

To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers-25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework.

CONCLUSIONS

By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy.

The Socioeconomic consequences of femoral shaft fracture for patients in Malawi

Background

Femoral shaft fractures are common in Malawi, with an annual incidence of 44 per 100,000 people. Inadequate treatment and delayed presentation often result in functional, biopsychosocial, and financial challenges for patients. The purpose of this study was to examine the socioeconomic consequences of femoral shaft fractures for patients in Malawi.

Methods

This study of 42 patients was part of a larger study that prospectively examined quality of life. Questionnaires were distributed to patients at 1-year follow-up following femoral shaft fracture treatment. Patients reported pre- and post-injury standard of living and financial well-being.

Results

Patients reported relatively high transportation costs to and from the hospital. One year after injury, 17 patients (40%) had not returned to work. Of the 25 (60%) who had returned, 5 (20%) changed jobs due to their injury, all reported decreased productivity. Household income decreased for 29% of patients. 20 (49%) of 41 patients reported food insecurity in the week prior to questionnaire completion. Many patients reported changing their residence, borrowing money, selling personal property, and unenrolling children from school due to financial hardship caused by their injury.

Conclusion

While the Malawian public healthcare system is free at the point of care, it lacks the financial risk protection that is essential to universal health coverage (UHC). In this study, we found that the indirect costs of care due to femoral shaft fractures had substantial socioeconomic consequences on the majority of patients and their families. Increased investment of financial and human capital should be made into capacity building and preventative measures to decrease the burden of injury, increase access to care, improve care delivery, and provide financial risk protection for patients with traumatic injuries in Malawi.

Fall-Related Injuries in Malawi: Outcomes and Trends Over Time

BACKGROUND

Fall-related injury (FRI) is a leading cause of injuries worldwide. Data on injury patterns and trends over time are lacking in resource-limited settings.

METHODS

We performed a retrospective analysis of FRI at Kamuzu Central Hospital in Malawi from 2009 to 2021. Outcomes were compared between patients presenting with FRI and those with other injury mechanisms. Bivariate and multivariate regressions were used to determine predictors of presentation following falls and mortality. We also analyzed time trends.

RESULTS

A total of 166,047 patients were included, of which 41,695 were patients presenting after falls (25.7%). Most FRI patients were between 5 and 45 (67.2%) and male (66.9%). Most falls occurred at home (67.3%) and resulted in extremity injuries (51.6%). The predicted probability of hospital presentation after falling is highest for children ≤  5 years and adults >  60 years and decreases over time. On multivariate analysis, patients between 5 and 15 [adjusted odds ratio (AOR) 1.70, 95% confidence interval (CI) 1.63-1.77] and > 60 (AOR 1.14, 95% CI 1.07-1.22) and women (AOR 1.13, 95% CI 1.10-1.16) are more likely to present with FRI. Compared to patients with non-FRI, those with FRI were more likely to have been injured at school (AOR 2.16, 95% CI 2.01-2.32) and during sports and recreation (AOR 4.53, 95% CI 4.24-4.85).

CONCLUSION

FRI is the most common injury presentation after motor vehicle injury in this low-resource setting. This study provides essential information about FRI in Malawi over time. Our findings can help inform resource allocation and injury prevention initiatives.

Delayed Presentation of a Nonunion of the Distal Femur Associated With a Missed Popliteal Artery Injury: A Case Report

Popliteal artery injuries are known complications of distal femur fractures, often leading to life-threatening consequences. The authors present a case of a four-month-old missed popliteal artery injury complicating a nonunion of the distal femur. The patient, a 28-year-old male, initially sought alternative treatment after a bike accident but experienced persistent pain and functional limitations. During our clinical evaluation, the possibility of a popliteal artery injury was considered but not definitively ruled out. However, during surgery, an incomplete transection of the popliteal artery was discovered, posing life-threatening complications. Fortunately, through effective management, we were able to address the complications and proceed with the planned procedure. This case underscores the importance of recognizing vascular damage in delayed fracture presentations and highlights the necessity of a prompt, multidisciplinary approach to handle unexpected surgical complications. Insights gained from this case contribute to raising awareness and preparedness among healthcare providers in similar challenging scenarios.

Clinical outcomes of ankle fractures in sub-Saharan Africa: a systematic review

PURPOSE

Ankle fractures may cause disability and socioeconomic challenges, even when managed in a high-resource setting. The outcomes of ankle fractures in sub-Saharan Africa are not widely reported. We present a systematic review of the patient-reported outcomes and complications of patients treated for ankle fractures in sub-Saharan Africa.

METHODS

Medline, Embase, Google Scholar and the Cochrane Central Register of Controlled Trials were searched, utilising MeSH headings and Boolean search strategies. Ten papers were included. Data included patient demographics, surgical and non-surgical management, patient-reported outcome measures and evidence of complications.

RESULTS

A total of 555 patients with ankle fractures were included, 471 of whom were followed up (range 6 weeks-73 months). A heterogenous mix of low-quality observational studies and two methodologically poor-quality randomised trials demonstrated mixed outcomes. A preference for surgical management was found within the published studies with 87% of closed fractures being treated operatively. A total of five different outcome scoring systems were used. Most studies included in this review were published by well-resourced organisations and as such are not representative of the actual clinical practice taking place.

CONCLUSION

The literature surrounding the clinical outcomes of ankle fractures in sub-Saharan Africa is sparse. There appears to be a preference for surgical fixation in the published literature and considering the limitations in surgical resources across sub-Saharan Africa this may not be representative of real-life care in the region.

Limb Injuries and Disability in the Southwest Region of Cameroon

INTRODUCTION

Extremity injuries are a leading cause of morbidity in low- and middle-income countries (LMICs), often resulting in marked short-term and long-term disabilities. Most of the existing knowledge on these injuries originates from hospital-based studies; however, poor access to health care in LMICs limits these data because of inherent selection bias. This subanalysis of a larger population-level cross-sectional study in the Southwest Region of Cameroon aims to determine patterns of limb injury, treatment-seeking behaviors, and predictors of disability.

METHODS

Households were surveyed in 2017 on injuries and subsequent disability sustained over the previous 12 months using a three-stage cluster sampling framework. Subgroups were compared using the chi square, Fisher exact, analysis of variance, Wald, and Wilcoxon rank-sum tests. Logarithmic models were used to identify predictors of disability.

RESULTS

Of 8,065 subjects, 335 persons (4.2%) sustained 363 isolated limb injuries. Over half of the isolated limb injuries (55.7%) were open wounds while 9.6% were fractures. Isolated limb injuries most commonly occurred in younger men and resulted from falls (24.3%) and road traffic injuries (23.5%). High rates of disability were reported, with 39% reporting difficulty with activities of daily living. Compared with individuals with other types of limb injuries, those with fractures were six times more likely to seek a traditional healer first for care (40% versus 6.7%), 5.3 times (95% CI, 1.21 to 23.42) more likely to have any level of disability after adjustment for injury mechanism, and 2.3 times more likely to have difficulty paying for food or rent (54.8% versus 23.7%).

DISCUSSION

Most traumatic injuries sustained in LMICs involve limb injuries and often result in high levels of disability that affect individuals during their most productive years. Improved access to care and injury control measures, such as road safety training and improvements to transportation and trauma response infrastructure, are needed to reduce these injuries.

Access to care following injury in Northern Malawi, a comparison of travel time estimates between Geographic Information System and community household reports

INTRODUCTION

Injuries disproportionately impact low- and middle-income countries like Malawi. The Lancet Commission on Global Surgery's indicators include the population proportion accessing laparotomy and open fracture care, key trauma interventions, within two hours. The "Golden Hour" for receiving facility-based resuscitation also guides injury care system strengthening. Firstly, we estimated the proportion of the local population able to reach primary, secondary and tertiary facility care within two and one hours using Geographic Information System (GIS) analysis. Secondly, we compared community household-reported with GIS-estimated travel time.

METHODS

Using information from a Health and Demographic Surveillance Site (Karonga, Malawi) on road network, facility location, and local staff-estimated travel speeds, we used a GIS-generated friction surface to calculate the shortest travel time from all households to each facility serving the population. We surveyed community households who reported travel time to their preferred, closest, government secondary and tertiary facilities. For recently injured community members, time to reach facility care was recorded. To assess the relationship between community household-reported travel time and GIS-estimated travel time, we used linear regression to generate a proportionality constant. To assess associations and agreement between injured patient-reported and GIS-estimated travel time, we used Kendall rank and Cohen's kappa tests.

RESULTS

Using GIS, we estimated 79.1% of households could reach any secondary facility, 20.5% the government secondary facility, and 0% the government tertiary facility, within two hours. Only 28.2% could reach any secondary facility within one hour, 0% for the government secondary facility. Community household-reported travel time exceeded GIS-estimated travel time. The proportionality constant was 1.25 (95%CI 1.21-1.30) for the closest facility, 1.28 (95%CI 1.23-1.34) for the preferred facility, 1.45 (95%CI 1.33-1.58) for the government secondary facility, and 2.12 (95%CI 1.84-2.41) for tertiary care. Comparing injured patient-reported with GIS-estimated travel time, the correlation coefficient was 0.25 (SE 0.047) and Cohen's kappa was 0.15 (95%CI 0.078-0.23), suggesting poor agreement.

DISCUSSION

Most households couldn't reach government secondary care within recognised thresholds indicating poor temporal access. Since GIS-estimated travel time was shorter than community-reported travel time, the true proportion may be lower still. GIS derived estimates of population emergency care access in similar contexts should be interpreted accordingly.

Clinical and functional outcomes of Paediatric femoral shaft fractures managed non-operatively at Nkhotakota District Hospital, Malawi

Background

Femoral shaft fracture is a common paediatric injury, managed non-operatively with skin traction in Malawian public hospitals. The clinical and functional outcomes of this treatment modality are unknown in Malawi.

Methods

We retrospectively identified all children who were managed at Nkhotakota District Hospital with skin traction after sustaining closed femoral shaft fractures from January 1, 2013 to December 31, 2016. We collected demographic characteristics and treatment history from the patient's inpatient medical records, then invited each patient to undergo in-person follow-up clinical and functional assessment.

Results

We identified 149 patients. Gallows traction 26 (17%) and 123 Bucks skin traction (83%). The mean age for Gallows traction was 10 months (95% CI: 8-11), most were males (16, 62%). Fall was the most common cause of injury (19, 73%), and mean hospitalization of 15.8 days (95% CI: 13.8-17.9). Eighteen patients (69%) were followed up at a mean of 4.2 years after discharge, all were full weight bearing, had achieved radiographic fracture union, and had no functional limitations or pain during regular activity. Buck's skin traction mean age was 5.2 years (95% CI: 4.7-5.8), most were males (82, 67%), and fall (85, 69%). We followed up 83 patients (67%) at a mean of 4.1 years after hospital discharge, all of whom had achieved radiographic fracture union. All but one patient were full weight bearing and had normal gait. At follow-up, 14 patients (17%) reported some level of pain, 5 patients reported that their injury limited their return to household chores, and 2 reported that their injury also limited their return to school.

Conclusion

Despite the limitations of this study, non-operative management of paediatric femoral shaft fractures at Nkhotakota District Hospital may have good clinical and functional outcomes and minimal complications. A future prospective study may be helpful to confirm these findings.

Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi

Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting.

Methods

We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment.

Results

We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures.

Conclusions

Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-Effectiveness analysis of the surgical management of fractures in Malawi: An economic evaluation of a high and low-income country surgical collaboration

INTRODUCTION

Cost-effectiveness is an essential tool for identifying high-value interventions in resource-limited settings. This study aims to evaluate the cost-effectiveness of the surgical management of fractures by surgical residents at Kamuzu Central Hospital (KCH). Currently, the 5-year surgical training program is supported by the Malawi Ministry of Health, and two universities in the United States and Norway.

METHODS

We performed a modeled cost-effectiveness analysis (CEA) from a public health sector perspective. Cost data were collected from the current residency program and effectiveness data estimated from clinical data derived from operative interventions for fractures between 2013 and 2017 at KCH. Three patient groups were used as the base case; (1) patients of all ages, (2) patients age ≥18 years, and (3) patients who were <18 years. A Monte Carlo simulation of 10,000 trials was conducted for the probabilistic sensitivity analysis.

RESULTS

The estimated average lifetime cost of training and compensating residency-trained surgeons over a 35-year career was $448,600 (SD $31,167). The incremental cost-effectiveness ratio (ICER) for providing surgical care to patients of all ages was $215 (SD $3,666) per disability-adjusted life-year (DALY), which is below the willingness-to pay-threshold (WTP) of $1,170 per DALY and highly cost-effective at a WTP threshold of $390. Each surgeon is estimated to avert approximately 5,570 DALYs during their career when performing operations to treat fractures.

CONCLUSION

The KCH surgical training program is highly cost-effective at reducing disability at an incremental cost of $215 per averted DALY. This CEA demonstrates that the current surgical training program is cost-effective in reducing morbidity among individuals with fractures.

Improving Management of Adult Ankle Fractures in Malawi: An Assessment of Providers' Knowledge and Treatment Strategies

BACKGROUND

The burden of musculoskeletal trauma is increasing worldwide, especially in low-income countries such as Malawi. Ankle fractures are common in Malawi and may receive suboptimal treatment due to inadequate surgical capacity and limited provider knowledge of evidence-based treatment guidelines.

METHODS

This study was conducted in 3 phases. First, we assessed Malawian orthopaedic providers' understanding of anatomy, injury identification, and treatment methods. Second, we observed Malawian providers' treatment strategies for adults with ankle fractures presenting to a central hospital. These patients' radiographs underwent blinded, post hoc review by 3 U.S.-based orthopaedic surgeons and a Malawian orthopaedic surgeon, whose treatment recommendations were compared with actual treatments rendered by Malawian providers. Third, an educational course addressing knowledge deficits was implemented. We assessed post-course knowledge and introduced a standardized management protocol, specific to the Malawian context.

RESULTS

In Phase 1, deficits in injury identification, ideal treatment practices, and treatment standardization were identified. In Phase 2, 17 (35%) of 49 patients met operative criteria but did not undergo a surgical procedure, mainly because of resource limitations and provider failure to recognize unstable injuries. In Phase 3, 51 (84%) of 61 participants improved their overall performance between the pre-course and post-course assessments. Participants answered a mean of 32.4 (66%) of 49 questions correctly pre-course and 37.7 (77%) of 49 questions correctly post-course, a significant improvement of 5.2 more questions (95% confidence interval [CI], 3.8 to 6.6 questions; p < 0.001) answered correctly. Providers were able to identify 1 more injury correctly of 8 injuries (mean, 1.1 questions [95% CI, 0.6 to 1.6 questions]; p < 0.001) and to identify 1 more ideal treatment of the 7 that were tested (mean, 1.0 question [95% CI, 0.5 to 1.4 questions]; p < 0.001).

CONCLUSIONS

Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery. This was due to resource limitations, knowledge deficits, and lack of treatment standardization. We demonstrated a comprehensive approach to examining the challenges of providing adequate orthopaedic care in a resource-limited setting and the successful implementation of an educational intervention to improve care delivery. This approach can be adapted for other conditions to improve orthopaedic care in low-resource settings.

Two success stories in the management of Guillain-Barré syndrome illustrate the challenges of intensive care unit care in Malawi

The management of critical illness is especially challenging in low-resource environments, and early recognition and supportive care are essential, regardless of the ability to employ advanced or invasive therapy. In this report, we discuss two patients with Guillain-Barré syndrome who were managed successfully in the intensive care unit of a tertiary hospital in Malawi. Both patients recovered and were discharged home. The management and outcomes of these patients provide case-based lessons for improving intensive care unit medicine in low-resource contexts.

Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries

There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.

Assessing the capacity of Malawi's district and central hospitals to manage traumatic diaphyseal femoral fractures in adults

Background

The burden of musculoskeletal trauma is growing worldwide, disproportionately affecting low-income countries like Malawi. However, resources required to manage musculoskeletal trauma remain inadequate. A detailed understanding of the current capacity of Malawian public hospitals to manage musculoskeletal trauma is unknown and necessary for effective trauma system development planning.

Methods

We developed a list of infrastructure, manpower, and material resources used during treatment of adult femoral shaft fractures–a representative injury managed non-operatively and operatively in Malawi. We identified, by consensus of at least 7 out of 10 experts, which items were essential at district and central hospitals. We surveyed orthopaedic providers in person at all 25 district and 4 central hospitals in Malawi on the presence, availability, and reasons for unavailability of essential resources. We validated survey responses by performing simultaneous independent on-site assessments of 25% of the hospitals.

Results

No district or central hospital in Malawi had available all the essential resources to adequately manage femoral fractures. On average, district hospitals had 71% (range 41–90%) of essential resources, with at least 15 of 25 reporting unavailability of inpatient ward nurses, x-ray, external fixators, gauze and bandages, and walking assistive devices. District hospitals offered only non-operative treatment, though 24/25 reported barriers to performing skeletal traction. Central hospitals reported an average of 76% (71–85%) of essential resources, with at least 2 of 4 hospitals reporting unavailability of full blood count, inpatient hospital beds, a procedure room, an operating room, casualty/A&E department clinicians, orthopaedic clinicians, a circulating nurse, inpatient ward nurses, electrocardiograms, x-ray, suture, and walking assistive devices. All four central hospitals reported barriers to performing skeletal traction. Operative treatment of femur fracture with a reliable supply of implants was available at 3/4 hospitals, though 2/3 were dependent entirely on foreign donations.

Conclusion

We identified critical deficiencies in infrastructure, manpower, and essential resources at district and central hospitals in Malawi. Our findings provide evidence-based guidance on how to improve the musculoskeletal trauma system in Malawi, by identifying where and why essential resources were unavailable when needed.