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.

An Assessment of Open Fracture Management in Hospitals in Malawi Before and Immediately After Implementing Open Fracture Guidelines.

Background: Open fractures, a common consequence of road traffic collisions, are associated with a high risk of complications. The introduction of standard guidelines has been shown to improve patient care and reduce the risk of complications in several countries. In September 2021, the Malawi Orthopaedic Association/Arbeitsgemeinschaft für Osteosynthesefragen Alliance (MOA/AOA) guidelines and standards for open fracture management were introduced in Malawi. This study aimed to assess the management of open fractures in hospitals in Malawi, before and after implementing a training course on the MOA/AOA open fracture guidelines. Methods: This was a descriptive and quantitative, before-and-after study that reviewed the medical files of patients with open fractures at Zomba Central Hospital and Mulanje, Salima, and Mangochi district hospitals over two 3-month periods. Variables included initial assessment; antibiotic prophylaxis; place of debridement; type of anesthesia; treatment of the open fracture in the emergency department, operating room, and wards; and short-term complications requiring hospital treatment. Results: A total of 88 open-fracture case files were reviewed; 43 were prior and 45 were subsequent to the implementation of the open fracture guidelines. The overall median patient age was 36 years (interquartile range, 27 to 45 years), and 91% (80) were male. Limb neurovascular status assessment and documentation improved from 26% (11) of the patients before the guidelines to 62% (28) afterward (p = 0.0002). The percentage who underwent debridement in the operating room significantly increased from 19% (8) to 69% (31) (p = 0.01). The percentage who underwent debridement under general or spinal anesthesia significantly increased from 5% (2) to 38% (17) and from 12% (5) to 29% (13), respectively (p= 0.001). The wound infection rate decreased from 21% to 11%, but this was not significant, and there was no change in the overall complication rate (p = 0.152). Conclusions: This study suggests that training on the MOA/AOA open fracture management guidelines followed by their implementation can lead to at least temporary improvement in the management of open fractures. Nevertheless, additional studies need to be performed to understand the effect on long-term patient outcomes. Levels of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Best Practices for Developing International Academic Partnerships in Orthopaedics.

ABSTRACT: Traumatic and nontraumatic orthopaedic conditions are major contributors to global morbidity and account for the majority of life-years lived with disability worldwide. Additionally, the burden of musculoskeletal injuries has increased substantially over the past 3 decades. Unfortunately, in low and middle-income countries (LMICs), access to orthopaedic care is limited, leading to a disproportionate burden of disease. The Lancet Commission on Global Surgery has emphasized the urgent need for unified international commitment and research collaboration to achieve universal access to safe and affordable surgical care. However, conducting high-quality orthopaedic research in LMICs remains challenging as a result of disparities in training, access to resources, infrastructure, and equipment availability. Partnerships between high-income countries (HICs) and LMICs have emerged in recent decades as an effective approach to combatting some of these challenges. These partnerships aim to bridge the gaps by facilitating collaborative research and knowledge exchange. The establishment of successful partnerships requires a collaborative and reciprocal approach that starts with a clear understanding of mutual research aims and the availability of resources. Despite the potential benefits, various factors can make establishing such partnerships difficult. However, these partnerships can have a substantial impact in delivering quality orthopaedic education and research training, thus improving access to care in resource-limited environments. This paper represents the collaborative effort of multiple international academic orthopaedic surgeons with extensive experience in HIC-LMIC partnerships. Our aims were to outline the best practices for conducting orthopaedic research within these relationships and to provide guidance for future successful collaborations.

Fall injuries in Sub-Saharan Africa: analysis of prospective injury registry from 23 health facilities in Malawi and Tanzania.

BACKGROUND: Low-and middle-income countries account for over 80% of fall-related fatalities globally. However there is little emphasis on the issue and limited high quality data to understand the burden, and to inform preventive and management strategies. We characterise the burden of fall injuries in Malawi and Tanzania. METHODS: This multi-centre prospective descriptive study utilized trauma registry data from 10 hospitals in Malawi and 13 hospitals in Tanzania. The study included twelve months of data in Tanzania (October 2019 to September 2020), and eighteen months of data from Malawi (September 2018 to March 2020). We describe patient demographics, the causes, location, and nature of injuries, timing of arrival to hospital, and final disposition. Regression analyses were performed to determine risk factors for serious injuries. RESULTS: There were 93,178 trauma patients in the registries of both countries, of which 44,609 (47.9%) had fall related complaints. Fall injuries accounted for 55.3% and 17.4% of all trauma cases in Malawi and Tanzania respectively. Overall the median age was 16 years (Interquartile range (IQR) 8-31 years), and 62.8% were male. Most fall injuries (69.9%) occurred at home, were unintentional (98.1%), and were due to a ground level fall (74.9%). Nearly half of patients (47.9%) arrived at a facility using public transport, with median arrival time of 10 h (IQR 8-13 h) from initial injury. Extremities (87.0%) were the most commonly injured region, followed by head and neck (4.4%). Overall 3275 (7.4%) patients had potentially serious injuries. Age > 60 years was associated with two times odds of having serious injuries than those < 5 years, and those sustaining injury at work (adjusted Odds Ratio (aOR) 1.95 95% CI; 1.56-2.43) or recreational areas (aOR 3.47 95% CI; 2.93-4.10) had higher odds of serious injuries compared to those injured at home. CONCLUSIONS: In these facilities in Sub-Saharan Africa, fall injuries accounted for a substantial fraction of all injuries. While most common in younger males, those aged 5-13 and over 60 years were more likely to have serious injuries. Most falls occurred at home, but serious injuries were more likely to occur at recreational and work areas. Future efforts should focus on preventive strategies to mitigate these injuries.

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 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.

"Don't rush into thinking of walking again": Patient views of treatment and disability following an open tibia fracture in Malawi.

Background: Open tibia fractures are a common injury following road traffic accidents in Malawi and can lead to long term disability. Very little is known about patients' experiences of the healthcare system and the disability in low-income countries following this injury. The aim of the study was to explore patient experiences of treatment and disability following an open tibia fracture in Malawi. Methods: A qualitative study was conducted using semi-structured interviews with ten patients with open tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic analysis was used to identify broad themes of treatment and disability. Written informed consent was obtained from all participants. Results: Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male. Broad themes found were delays in receiving treatment, change in individuals' societal role and delayed recovery associated with pain and immobility. Conclusions: Open tibia fractures in Malawi have a devastating impact on patients and their families. Further studies are required to explore the reasons for the delays in open fracture emergency treatment.

Epidemiology of adult trauma injuries in Malawi: results from a multisite trauma registry.

BACKGROUND: Large-scale multisite trauma registries with broad geographic coverage in low-income countries are rare. This lack of systematic trauma data impedes effective policy responses. METHODS: All patients presenting with trauma at 10 hospitals in Malawi from September 2018 to March 2020 were enrolled in a prospective registry. Using data from 49,241 cases, we analyze prevalence, causes, and distribution of trauma in adult patients, and timeliness of transport to health facilities and treatment. RESULTS: Falls were the most common mechanism of injury overall, but road traffic crashes (RTCs) were the most common mechanism of serious injury, accounting for (48%) of trauma admissions. This pattern was consistent across all central and district hospitals, with only one hospital recording < 40% of admissions due to RTCs. 49% of RTC-linked trauma patients were not in motorized vehicles at the time of the crash. 84% of passengers in cars/trucks/buses and 48% of drivers of cars/trucks/buses from RTCs did not wear seatbelts, and 52% of motorcycle riders (driver and passenger) did not wear helmets. For all serious trauma cases (defined as requiring hospital admission), median time to hospital arrival was 5 h 20 min (IQR 1 h 20 min, 24 h). For serious trauma cases that presented on the same day that trauma occurred, median time to hospital arrival was 2 h (IQR 1 h, 11 h). Significant predictors of hospital admission include being involved in an RTC, age > 55, Glasgow Coma Score < 12, and presentation at hospital on a weekend. CONCLUSIONS: RTCs make up almost half of hospitalized trauma cases in this setting, are equally common in referral and district hospitals, and are an important predictor of injury severity. Pedestrians and cyclists are just as affected as those in vehicles. Many of those injured in vehicles do not take adequate safety precautions. Most trauma patients, including those with serious injuries, do not receive prompt medical attention. Greater attention to safety for both motorized and especially non-motorized road users, and more timely, higher quality emergency medical services, are important policy priorities for Malawi and other developing countries with high burdens of RTC trauma.

Childhood musculoskeletal impairment in Malawi from traumatic and non-traumatic causes: a population- based assessment using the key informant method.

BACKGROUND: Musculoskeletal impairment (MSI) in children is an under-recognised public health challenge. Although preventable, road injuries and other traumas continue to cause significant impairments to children worldwide. The study aimed to use the Key Informant Method (KIM) to assess prevalence and causes of MSI in children in two districts in Malawi, estimating the associated need for services provision, with a focus on traumatic aetiology. METHODS: The KIM was conducted in the districts of Thyolo (Southern Malawi) and Ntcheu (Central Malawi) in 2013. Five hundred key informants were trained to identify children who may have one of a range of MSI. The identified children were referred to a screening camp where they were examined by medical experts with standardised assessment protocols for diagnosing each form of impairment. RESULTS: 15,000 children were referred to screening camps. 7220 children were assessed (response rate 48%) for an impairment of whom 15.2% (1094) had an MSI. 13% of children developed MSI from trauma, while 54% had a neurological aetiology. For MSI of traumatic origin the most common body part affected was the elbow. Less than half of children with MSI (44.4%) were enrolled in school and none of these children attended schools with resources for disability. More than half of children with MSI (60%) had not received required services and 64% required further physical therapy. CONCLUSIONS: The KIM method was used to identify a high prevalence of MSI among children in two districts of Malawi and estimates an unmet need for dedicated MSI services.

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.

Epidemiology of fractures and their treatment in Malawi: Results of a multicentre prospective registry study to guide orthopaedic care planning.

IMPORTANCE: Injuries cause 30% more deaths than HIV, TB and malaria combined, and a prospective fracture care registry was established to investigate the fracture burden and treatment in Malawi to inform evidence-based improvements. OBJECTIVE: To use the analysis of prospectively-collected fracture data to develop evidence-based strategies to improve fracture care in Malawi and other similar settings. DESIGN: Multicentre prospective registry study. SETTING: Two large referral centres and two district hospitals in Malawi. PARTICIPANTS: All patients with a fracture (confirmed by radiographs)-including patients with multiple fractures-were eligible to be included in the registry. EXPOSURE: All fractures that presented to two urban central and two rural district hospitals in Malawi over a 3.5-year period (September 2016 to March 2020). MAIN OUTCOME(S) AND MEASURE(S): Demographics, characteristics of injuries, and treatment outcomes were collected on all eligible participants. RESULTS: Between September 2016 and March 2020, 23,734 patients were enrolled with a median age of 15 years (interquartile range: 10-35 years); 68.7% were male. The most common injuries were radius/ulna fractures (n = 8,682, 36.8%), tibia/fibula fractures (n = 4,036, 17.0%), humerus fractures (n = 3,527, 14.9%) and femoral fractures (n = 2,355, 9.9%). The majority of fractures (n = 21,729, 91.6%) were treated by orthopaedic clinical officers; 88% (20,885/2,849) of fractures were treated non-operatively, and 62.7% were treated and sent home on the same day. Open fractures (OR:53.19, CI:39.68-72.09), distal femoral fractures (OR:2.59, CI:1.78-3.78), patella (OR:10.31, CI:7.04-15.07), supracondylar humeral fractures (OR:3.10, CI:2.38-4.05), ankle fractures (OR:2.97, CI:2.26-3.92) and tibial plateau fractures (OR:2.08, CI:1.47-2.95) were more likely to be treated operatively compared to distal radius fractures. CONCLUSIONS AND RELEVANCE: The current model of fracture care in Malawi is such that trained orthopaedic surgeons manage fractures operatively in urban referral centres whereas orthopaedic clinical officers mainly manage fractures non-operatively in both district and referral centres. We recommend that orthopaedic surgeons should supervise orthopaedic clinical officers to manage non operative injuries in central and district hospitals. There is need for further studies to assess the clinical and patient reported outcomes of these fracture cases, managed both operatively and non-operatively.

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.

Characteristics of interpersonal violence in adult victims at the Adult Emergency Trauma Centre (AETC) of Queen Elizabeth Central Hospital.

Introduction: Globally, the burden of interpersonal violence and its significant impact on mortality, morbidity and disability makes it a major public health problem which necessitates intervention. This article examines characteristics of victims of interpersonal violence and violent events in Malawi. The focus is on a population that has been traditionally neglected in literature. Methods: Queen Elizabeth Central Hospital (QECH) maintains a trauma registry with data that is prospectively collected. Patients offered trauma care after interpersonal violence from May 2013 to May 2015 were evaluated. Results: There were 1431 patients with violent events recorded at the Adult Emergency Trauma Centre (AETC) with a male predominance of 79.5%. The dominant age group was young adults between 25-29 years old (22%). Most attacks occurred during cold and dry season (46.9%) and most common location was on the road (37.2%). Alcohol use by victims was recorded in 10.5% of cases. Soft tissue injuries were the most common injuries sustained (74.1%). Most patients were treated as outpatients (80.9%). There were two deaths. At multivariate analysis, women had a lower risk of interpersonal violence as compared to men, (OR 0.82 [0.69-0.98]). Victims' use of alcohol was associated with increased risk of assault (OR 1.63 [1.27-2.10]). As compared to other places, odds of being assaulted were higher at home (OR 1.62 [1.27-2.06]) but lower at work (OR 0.68 [0.52-0.89) and on the road (OR 0.82 [0.65-1.03]). Odds of being assaulted were higher in the cold and dry season as compared to hot and dry season, (OR 1.26 [1.08-1.47]). Conclusion: Young males were most involved in interpersonal violence. Location of injury and seasonal variation were significant factors associated with interpersonal violence and most commonly sustained injuries were soft tissue injuries. These findings will help in identifying targeted interventions for interpersonal violence in Malawi and other low-and-middle-income countries (LMICs).

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi.

Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.

Implementation of a multi-center digital trauma registry: Experience in district and central hospitals in Malawi.

BACKGROUND: Trauma is a rapidly growing component of the burden of disease in developing countries; yet systematic data collection about trauma in such contexts is relatively rare. METHODS: This paper describes the implementation of a trauma registry in 10 government-run hospitals in Malawi, with a focus on implementation logistics, stakeholder engagement strategies, and data quality procedures. RESULTS: 51 337 trauma cases were recorded over the first 14 months of registry operations. The number of cases per month, data accuracy, and the geographic coverage of the registry improved over time as data quality measures were implemented. CONCLUSIONS: Multi-center digital trauma registries are feasible in low-resource settings. Stakeholder engagement, periodic in-person and frequent digital follow up with data teams, and regular channeling of findings back to data collection teams help to improve data quality and completeness over a 14 month period. Financial and staffing constraints remain challenges for sustainability over time, but this experience demonstrates the feasibility of large-scale registry operations.