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.

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.

The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study.

Background: Operative note writing is one of the fundamental parts in surgical practice. Accurate documentation is critical, to be of value when used for postoperative care, research, academic purposes and medical legal clarity. Although guidelines guiding surgeons on how to write operative notes exist, deficiencies are noted worldwide. Purpose: To assess quality of hand-written operative notes in surgical unit at Queen Elizabeth Central Hospital (QECH) using the RCSEng guidelines as a standard. Methods: To identify key areas of weaknesses, a sole observer in this study assessed prospectively the quality of operative notes in our setting. The audit loop was completed after adoption of new interventions. Results: Sixty-seven percent of the notes were written by trainees in both audits. Key areas of missing data were on time of performing the operation, urgency, estimated blood loss, complications and extra procedure in the first audit, with a frequency of 0%, 2%, 14%, 38% and 11% respectively. The results improved significantly to 62%, 84%, 62%, 70%and 32% respectively [p<0.05] in the second audit. Half of the postoperative care instructions were inadequate with 29% of the notes partially illegible or completely illegible. Conclusion: The study identifies significant deficiencies in our operative note writing. Surgeon's education, use of detailed pro formas with heading prompts and aide memoirs for vital information play a major role in better note completion. The role of electronic health records is highlighted.