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PLoS One. 2019 Nov 20;14(11):e0225254. doi: 10.1371/journal.pone.0225254. eCollection 2019.

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

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Harvard Combined Orthopaedic Residency Program, Boston, MA, United States of America.
The Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, United States of America.
Department of Orthopedics, Queen Elizabeth Central Hospital, Blantyre, Malawi.
Department of Orthopedics, Haukeland University Hospital, Bergen, Norway.
Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi.
College of Medicine, University of Malawi, Blantyre, Malawi.
Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi.
Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America.
Departments of Epidemiology and Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.



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.


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.


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.


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.

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