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

Autoři: Kiran J. Agarwal-Harding aff001;  Linda Chokotho aff003;  Sven Young aff004;  Nyengo Mkandawire aff003;  Mabvuto Chawinga aff005;  Elena Losina aff002;  Jeffrey N. Katz aff002
Působiště autorů: Harvard Combined Orthopaedic Residency Program, Boston, MA, United States of America aff001;  The Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, Boston, MA, United States of America aff002;  Department of Orthopedics, Queen Elizabeth Central Hospital, Blantyre, Malawi aff003;  Department of Orthopedics, Haukeland University Hospital, Bergen, Norway aff004;  Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi aff005;  College of Medicine, University of Malawi, Blantyre, Malawi aff006;  Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi aff007;  Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America aff008;  Departments of Epidemiology and Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America aff009
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0225254



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.

Klíčová slova:

Geological surveys – Inpatients – Malawi – Musculoskeletal injury – Nurses – Orthopedic surgery – Surveys – Traumatic injury


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2019 Číslo 11