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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]

Background Malawi has a rising burden of musculoskeletal trauma, coupled with insufficient surgical capacity to manage common, debilitating injuries like femoral shaft fractures. Nonoperative treatment remains the standard of care, with surgery available only at central hospitals. We sought to understand how patients navigate the Malawian health system and the barriers they face while seeking care. Methods We performed in-depth, semistructured interviews of 15 adults with closed femoral shaft fractures during their hospitalization at Kamuzu Central Hospital, a public referral hospital in Lilongwe--Malawi's capital city. We additionally interviewed 1 patient who left Kamuzu Central Hospital to seek care at a private hospital. An English-speaking investigator performed all interviews with a Chichewa-speaking medical interpreter. Interviews focused on patients' pathways from injury to present treatment (health system navigation), impressions of the hospital and care received, and the effects of injury and treatment on patients and their families. Interviews were audio recorded, translated, and transcribed in English. We coded the transcripts and performed thematic analysis. Results We identified 6 themes: high variability in health system navigation; frustrations with the biopsychosocial effects of hospitalization; lack of participation in decision-making and uncertainty about treatment course; preference for surgery (vs traction) based on patients' experiences and observations; frustrations with the inequitable provision of surgery; and patients' resignation, acceptance, and resilience in the face of hardship. Many patients receiving nonoperative treatment described the devastating financial burden imposed upon them and their families by their injuries and prolonged hospitalization. These patients viewed nonoperative treatment as inferior to surgery and suspected that richer patients were receiving more timely care. Conclusions This qualitative study suggested a need to standardize care for femoral shaft fractures in Malawi, increase the availability and timeliness of surgery, and increase transparency and communication between providers and patients. These remedies should focus on improving the quality of care and achieving equity in access to care. [ABSTRACT FROM AUTHOR]

Background Diagnostics are foundational to effective health systems but remain widely unavailable worldwide, especially in low-income countries like Malawi. To achieve health equity in Malawi, it is necessary to assess the availability of essential diagnostics. Methods We analysed data collected during a nationwide survey of musculoskeletal trauma care capacity. We analysed the presence, availability, and reasons for unavailability of laboratory testing, vital signs monitoring, electrocardiography, and diagnostic radiology at all 25 district hospitals and 4 central hospitals in Malawi. We used geospatial models to estimate the proportion of the Malawian population with 1-hour and 2-hour access to these resources. Taking 1-hour access to most accurately represent geospatial coverage in the Malawian context, a hypothetical intervention was designed whereby diagnostic capacity improvement would be prioritized at selected hospitals to cover at least 75% of Malawians nationwide. Results Twelve of 29 hospitals had basic laboratory testing available when needed, covering an estimated 58% of Malawians with 1-hour access and 95% with 2-hour access. Vital signs monitoring was available when needed at 18 hospitals, covering an estimated 74% of Malawians with 1-hour access and 97% with 2-hour access. Six hospitals reported that electrocardiography was available when needed, covering an estimated 49% of Malawians with 1-hour access and 91% with 2-hour access. Four hospitals had x-ray capacity of adequate quality to make accurate diagnoses when needed, covering an estimated 39% of Malawians with 1-hour access and 86% with 2-hour access. Broken machinery, inadequate supplies, and inadequate staff training were common reasons for resource unavailability. Conclusions Essential diagnostics were found to be unavailable for many Malawians. By prioritizing capacity improvements for all 4 central hospitals and 11 district hospitals, over three-quarters of Malawians could have 1-hour access to laboratory testing, vital signs monitoring, electrocardiography, and diagnostic x-ray. These capacity improvements are essential to meet the needs of a growing population, especially in the context of the current COVID-19 pandemic. [ABSTRACT FROM AUTHOR]