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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) [ABSTRACT FROM AUTHOR]

Background Injuries, disorders, and deformities of the hands and upper extremities cause significant morbidity worldwide, but in sub-Saharan Africa, the burden of disease and the availability of appropriate care remain unknown. We sought to characterize disease burden and barriers to care for hand and upper extremity conditions across sub-Saharan Africa, examining differences in burden and access by geographic region and national income level. Methods From 6 June 2020 through 17 March 2021, we surveyed providers of musculoskeletal care in sub-Saharan Africa regarding the provision of care and the most common acute and chronic hand or upper extremity conditions encountered by respondents. Surveys were distributed through professional networks across sub-Saharan Africa. We categorized responses by each respondent’s national income level and geographic region. Then, we examined how frequently various challenges to accessing healthcare, as well as how frequently acute or chronic conditions, were reported. Additionally, we analyzed how these data varied by income level and geographic region. Results We received 193 responses from 39 countries in sub-Saharan Africa. Eighty-eight per cent of respondents reported that general orthopaedic surgeons and orthopaedic traumatologists primarily manage upper extremity conditions. A lack of adequate and timely diagnosis was reported by 142 respondents (74%); late referral for treatment was reported by 149 (77%); and inadequate physical therapy, occupational therapy, and rehabilitation was reported by 149 respondents (77%). The most commonly reported acute conditions were adult and paediatric radius/ulna fractures/dislocations, adult metacarpal/phalangeal fractures/dislocations, soft-tissue injuries (including burns), and paediatric elbow fractures/dislocations. The most commonly reported chronic conditions were tendinitis/tenosynovitis, chronic infections/osteomyelitis, neuropathies, posttraumatic stiff hand, and radius/ulna malunion/nonunion. Neglected trauma (including chronic elbow injuries and burn contractures) was frequently reported, especially in low-income countries. Conclusions Trauma care should be strengthened through training of general orthopaedic surgeons in hand and upper extremity surgery throughout sub-Saharan Africa. Especially in low-income countries, particular training emphasis should be placed on the management of malunion/nonunion, osteomyelitis, acute and chronic elbow injuries, and burn contractures. These findings should inform the development of core competencies in hand surgery for providers managing musculoskeletal conditions in sub-Saharan Africa, as well as guide capacity-building activities on the continent. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aims: Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation., Methods: This systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available., Conclusion: The lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care., Competing Interests: M. Pigeolet received publication support for this article from the Belgian University Foundation (WA-0544) and the Harvard Global Orthopaedic Collaboration. M. Pigeolet received a grant from the Belgian Kids’ Fund for Pediatric Research, which had had no influence on any aspect of this article. J. K. Agarwal-Harding, M. R. Askew, S. R. Bradley, and A. Shah received publication support for this article from the Harvard Global Orthopaedic Collaborative., (© 2024 Pigeolet et al.)

Musculoskeletal injuries are common in Cameroon. Negative pressure wound therapy (NPWT) can effectively manage complex wounds including open fractures, however high cost and unavailability prevent its widespread use. We sought to evaluate the feasibility and efficacy in Cameroon of a low-cost NPWT (LCNPWT) device built from an aquarium pump costing less than $100. We performed a prospective case series including all patients with musculoskeletal injuries managed with LCNPWT at Baptist Hospital Mutengene, Mutengene, Cameroon from 15 th March 2021 to 15 th March 2022. Patient demographics, wound characteristics, and wound photographs were collected at intake and at each dressing change (performed every 3 days). All treatment was provided inpatient, and outcomes were recorded at hospital discharge. Forty-one patients (mean age 40 years, 58% male) received LCNPWT. The most common injury mechanisms were road traffic-related accidents (n=16, 42%) and gunshots (n=8, 21%). Wound characteristics were recorded for 38 patients of which 24 (63%) had infected wounds and 3 were bacteremic (13%) on presentation. All patients received antibiotics. The average duration of LCNPWT was 5.9 days (standard deviation 3.1 days). For 15 patients with documented outcome data, LCNPWT was successful in achieving wound closure in 12 (80%). Five patients failed limb salvage, with 4 receiving amputations and 1 dying during hospitalization. Eighty-three percent of providers (15 providers) reported LCNPWT as beneficial in managing wounds. Low-cost NPWT device was effective for managing contaminated and complex wounds in a resource-limited setting., Competing Interests: The authors declare no competing interests., (Copyright: Lahin Amlani et al.)

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., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

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., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)