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.