Open Exploration and Reduction of Paediatric Supracondylar Humerus Fracture with Pink, Pulseless Hand in Resource-Limited Settings.

Background: Supracondylar humerus fractures (SHFs) are common paediatric injuries, with high risk of vascular compromise. Some patients present with a 'pink, pulseless hand', caused by occlusion of brachial artery flow but with collateral circulation preserving distal perfusion. Management of these patients remains controversial, especially when resources may be limited for prolonged hospitalisation and serial monitoring by skilled staff. The aim of this study is to present the intraoperative findings, surgical procedures done and outcomes at 6 weeks for patients with paediatric supracondylar fractures with a pink pulseless hand. Methods: We retrospectively identified 13 patients who presented to a public hospital between January 2019 and May 2023 with a displaced SHF and pink, pulseless hand. All patients underwent an open reduction with an anterior approach allowing for exploration, protection and repair of neurovascular structures. Distal flow was restored in the brachial artery either with topical lidocaine application, thrombectomy or artery reconstruction. Results: Out of 13 patients, all had intact median nerves and 10 had intact arteries (69%), of which seven were interposed at the fracture site and four were in vasospasm. Of the three patients with true arterial injury (23%), two had a crushed artery and one had thrombosis of the artery. Peripheral pulses were restored within an hour of fracture open reduction in all patients. At final follow-up, a mean 6 weeks postoperatively, all patients had recovered without neurovascular deficit, compartment syndrome or Volkmann ischemic contracture. Conclusions: In resource-limited settings, we recommend performing open exploration and reduction for patients with SHFs with pink, pulseless hand. This approach prevents iatrogenic neurovascular injury during closed reduction attempts, allows for immediate repair of a brachial artery injury and avoids unnecessary hospitalisation and serial monitoring. Level of Evidence: Level IV (Therapeutic).

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.

The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States.

ABSTRACT: Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.

International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries.

ABSTRACT: Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

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 utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi.

Background and purpose - In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST.Patients and methods - This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty.Results - Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66-0.76) and 0.77 (CI 0.71-0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer's perspective, or $1,035 from the societal perspective.Interpretation - IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.

Implementation and Impact Evaluation of a Virtual Orthopaedic Continuing Medical Education Conference in a Low-Resource Country.

OBJECTIVE: The Haitian Annual Assembly of Orthopaedic Trauma (HAAOT) is an annual continuing medical education (CME) conference for Haitian orthopedists and trainees converted to a pilot virtual format in 2020 due to the COVID-19 pandemic. We evaluated this virtual format's effectiveness at teaching, facilitating bilingual discussion, and encouraging cross-cultural exchange of experiences - all aimed at improving orthopedic knowledge in a low-resource country like Haiti. DESIGN: Planned collaboratively between North American and Haitian colleagues, the conference involved 4 bilingual weekly Zoom meetings comprised of 4 to 6 prerecorded presentations and live-translated discussion. Pre- and postmeeting knowledge assessments in French (Haitian language of medical instruction) were administered weekly with results compared via 2-sample t-tests. An online postconference survey evaluated attendee satisfaction with the virtual format. SETTING: Virtual. PARTICIPANTS: Weekly attendance involved approximately 50 Haitian orthopedists and trainees, with 20 to 25 completing pre- and postmeeting assessments. RESULTS: Statistically significant increases between pre/post scores were seen during 3 of 4 sessions. Session-wide significant score increases occurred for residents and attending surgeons with <10 years of experience. 85.7% of attendees reported the virtual platform exceeded expectations and 100% indicated likely or extremely likely participation in further virtual events. CONCLUSIONS: The pilot virtual HAAOT was extremely well received with high desire for future sessions. Beyond short-term knowledge retention among attendees, nonmeasurable benefits included collaboration between orthopedists and trainees in the United States, Canada, United Kingdom, Haiti, and Burkina Faso. As COVID-19 spurs online learning in high-income nations, the successful low-resource context adjustments and local partnership underlying this model attest that travel restrictions need not impede delivery of virtual CME conferences in lower-income nations. Attendee learning and the decreased cost and travel requirements allude to this platform's sustainability and reproducibility in facilitating future international education and capacity building. Further studies will assess long-term retention of presented material.

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.

Outcomes Measurement in Global Hand Surgery.

The global burden of musculoskeletal trauma is high. There is a need to improve access to safe, high-quality surgery in many low- and middle-income countries (LMICs). Numerous initiatives have taken aim at solving this underlying shortage in surgical care, including mission trips, academic programs, and international collaborations. However, much work remains to be done in LMICs compared with high-income countries (HICs). In HICs, the field of hand surgery has grown partially owing to the rigorous application of clinical research to examine outcomes and determine best practices. Patient-reported outcome measures (PROMs) have a key role as a valid patient-centered method of capturing symptoms and well-being. They have substantial promise in LMICs to understand patient symptom severity and quality of life better, monitor treatment success or failure, determine cost-effectiveness of procedures, and guide capacity building. Contextually appropriate PROMs can improve routine follow-up in LMICs and advance the practice and study of hand surgery worldwide.

Supracondylar humerus fractures in low- and lower middle-income countries: a scoping review of the current epidemiology, treatment modalities, and outcomes.

BACKGROUND: The purpose of this scoping review was to examine the nature and quality of research regarding paediatric supracondylar humerus (SCH) fractures in low and lower middle-income countries (LICs). METHODS: We searched PubMed, Embase, Web of Science, and African Journals Online on January 9, 2018, for studies of SCH fractures in LICs. Studies were categorized by geographic region, Gartland classification of included patients, and study design. We evaluated each study's methodology and conclusions. RESULTS: Out of 1805 results, we analyzed 105 studies, most of which included type 3 fractures only (66%). Many were conducted in South Asia (58%) and assessed treatment outcomes (78%). Most of the studies had level IV evidence (67%). Common limitations of research were small sample size (12%) and inadequate follow-up (6%). Epidemiological studies concluded that SCH fractures are more common among male children, are usually secondary to falls, and rarely present with nerve injuries. Most therapeutic studies reported outcomes of surgery (91%). Thirteen studies concluded that all-lateral versus cross-pinning techniques have similar outcomes. Seven studies reported preference for closed reduction over open reduction, when intra-operative fluoroscopy was available. Most common outcome measures were Flynn criteria (77%) and range of motion (53%). None of the papers looked at treatment costs. CONCLUSIONS: Our data show a predominance of small level IV studies from LICs, with few studies of higher level of evidence. Many studies examined controversies with surgical technique, similar to studies performed in high-income countries. Few studies examined non-operative treatment, which is commonly the predominant treatment available for patients in LICs. Further investigation of common treatment modalities and outcomes for SCH fractures in LICs is needed.

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.

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

BACKGROUND: The burden of injuries is high in low-income and middle-income countries such as Malawi, where access to musculoskeletal trauma care is limited. Delayed treatment can worsen trauma-related disability. Understanding risk factors for delayed hospital presentation will assist in guiding trauma system development. METHODS: We examined the records of 1,380 pediatric and adult patients with fractures who presented to the orthopaedic clinics of 2 urban referral hospitals and 2 rural district hospitals in Malawi. We used multivariate Poisson regression to evaluate the association between presentation to a hospital ≥2 days after the injury (delayed presentation) and 11 covariates: age, sex, education level, occupation, season of injury, day of injury, injury mechanism, injury type or extremity of injury, referral status, hospital of presentation, and estimated travel time. RESULTS: Twenty-eight percent of pediatric patients and 34% of adult patients presented late. In the pediatric cohort, fall (relative risk [RR], 1.40 [95% confidence interval (CI), 1.02 to 1.93]), sports injuries (RR, 1.65 [95% CI, 1.09 to 2.49]), tibial or fibular injuries (RR, 1.36 [95% CI, 1.05 to 1.77]), injury over the weekend (RR, 2.30 [95% CI, 1.88 to 2.80]), estimated travel time of ≥20 minutes (RR, 1.45 [95% CI, 1.16 to 1.81]), referral from another facility (RR, 1.46 [95% CI, 1.05 to 2.02]), and presentation to Kamuzu Central Hospital, Mangochi District Hospital, or Nkhata Bay District Hospital (RR, 1.34 [95% CI, 1.07 to 1.69]) independently increased the risk of delayed presentation. In the adult cohort, fall (RR, 1.85 [95% CI, 1.38 to 2.46]), injury over the weekend (RR, 1.80 [95% CI, 1.38 to 2.36]), estimated travel time ≥20 minutes (RR, 1.36 [95% CI, 1.03 to 1.80]), and presentation to Kamuzu Central Hospital (RR, 1.74 [95% CI, 1.30 to 2.33]) independently increased the risk of delayed presentation. CONCLUSIONS: Delayed presentation to the hospital after a musculoskeletal injury is common in Malawi. Interventions are needed to improve access to musculoskeletal trauma care, especially for pediatric patients with tibial or fibular injuries, all patients after falls, patients injured over the weekend, and patients living far from health facilities.

Understanding and Addressing the Global Need for Orthopaedic Trauma Care.

➤The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.➤Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.➤The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.➤Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.➤Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.➤Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics.

Estimating the global incidence of femoral fracture from road traffic collisions: a literature review.

BACKGROUND: Worldwide, road injuries cause over 1.3 million deaths and many more disabilities annually, disproportionately affecting the young and the poor. Approximately one in ten road injuries involves a femoral shaft fracture that is most effectively treated with surgery. Current femoral shaft fracture incidence according to country and age group is unknown and difficult to measure directly but is critical to designing and evaluating interventions. METHODS: We modeled femoral shaft fracture incidence from road traffic collisions with use of World Bank, World Health Organization, and Global Burden of Disease Study data for 176 countries and five age groups. We used road traffic death rates, ratios of road traffic deaths to injuries, and proportions of road traffic injuries that were femoral shaft fractures to calculate the fracture incidence. RESULTS: The worldwide annual femoral shaft fracture incidence from road traffic collisions was between 1.0 and 2.9 million. Incidence rates were significantly higher in low and middle income countries compared with high income countries. Overall, low and middle income countries had a mean femoral shaft fracture incidence between 15.7 and 45.5 per 100,000 people per year, with a rate ratio of 2.08 (95% confidence interval, 2.02 to 2.13; p < 0.001) relative to high income countries. CONCLUSIONS: Our results demonstrate a substantial worldwide burden and disparities in femoral shaft fracture incidence between low to middle income and high income countries, and the young are disproportionately affected, underscoring the potential impact of improved access to treatment. We believe that the methodology of this study can be applied to estimate the burden of other diseases, allowing for better direction of global health efforts.

Health and economic benefits of improved injury prevention and trauma care worldwide.

OBJECTIVES: Injury is a significant source of morbidity and mortality worldwide, and often disproportionately affects younger, more productive members of society. While many have made the case for improved injury prevention and trauma care, health system development in low- and middle-income countries is often limited by resources. This study aims to determine the economic benefit of improved injury prevention and trauma care in low- and middle-income countries. METHODS: This study uses existing data on injury mortality worldwide from the 2010 Global Burden of Disease Study to estimate the number of lives that could be saved if injury mortality rates in low- and middle-income countries could be reduced to rates in high-income countries. Using economic modeling--through the human capital approach and the value of a statistical life approach--the study then demonstrates the associated economic benefit of these lives saved. RESULTS: 88 percent of injury-related deaths occur in low- and middle-income countries. If injury mortality rates in low- and middle-income countries were reduced to rates in high-income countries, 2,117,500 lives could be saved per year. This would result in between 49 million and 52 million disability adjusted life years averted per year, with discounting and age weighting. Using the human capital approach, the associated economic benefit of reducing mortality rates ranges from $245 to $261 billion with discounting and age weighting. Using the value of a statistical life approach, the benefit is between 758 and 786 billion dollars per year. CONCLUSIONS: Reducing injury mortality in low- and middle-income countries could save over 2 million lives per year and provide significant economic benefit globally. Further investments in trauma care and injury prevention are needed.

Modeling of CSF dynamics: legacy of Professor Anthony Marmarou.

The mathematical model of cerebrospinal fluid (CSF) pressure volume compensation, introduced by Anthony Marmarou in 1973 and modified in later studies, provides a theoretical basis for differential diagnosis in hydrocephalus. The Servo-Controlled Constant Pressure Test (Umea, Sweden) and Computerised Infusion Test (Cambridge, UK) are based on this model and are designed to compensate for inadequate accuracy of estimation of both the resistance to CSF outflow and elasticity of CSF pressure volume compensation.Dr. Marmarou's further works introduced the pressure volume index (PVI), a parameter used to describe CSF compensation in hydrocephalic children and adults. A similar technique has been also utilized in traumatic brain injury (TBI).The presence of a vascular component of intracranial pressure (ICP) was a concept proposed in the 1980s. Marmarou demonstrated that only around 30% of cases of elevated ICP in patients with TBI could be explained by changes in CSF circulation. The remaining 70% of cases should be attributable to vascular components, which have been proposed as equivalent to raised brain venous pressure.Professor Marmarou's work has had a direct impact in the field of contemporary clinical neurosciences, and many of his ideas are still being investigated actively today.

Variation of hamstrings lengths and velocities with walking speed.

Crouch gait, one of the most prevalent movement abnormalities among children with cerebral palsy, is frequently treated with surgical lengthening of the hamstrings. To assist in surgical planning many clinical centers use musculoskeletal modeling to help determine if a patient's hamstrings are shorter or lengthen more slowly than during unimpaired gait. However, some subjects with crouch gait walk slowly, and gait speed may affect peak hamstring lengths and lengthening velocities. The purpose of this study was to evaluate the effects of walking speed on hamstrings lengths and velocities in a group of unimpaired subjects over a large range of speeds and to determine if evaluating subjects with crouch gait using speed matched controls alters subjects' characterization as having "short" or "slow" hamstrings. We examined 39 unimpaired subjects who walked at five different speeds. These subjects served as speed-matched controls for comparison to 74 subjects with cerebral palsy who walked in crouch gait. Our analysis revealed that peak hamstrings length and peak lengthening velocity in unimpaired subjects increased significantly with increasing walking speed. Fewer subjects with cerebral palsy were categorized as having hamstrings that were "short" (31/74) or "slow" (38/74) using a speed-matched control protocol compared to a non-speed-matched protocol (35/74 "short", 47/74 "slow"). Evaluation of patients with cerebral palsy using speed-matched controls alters and may improve selection of patients for hamstrings lengthening procedures.