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Objective To assess the impact of an open fracture intervention bundle on clinical management and patient outcomes of adults in Malawi with open tibia fractures. Methods We conducted a before-and-after implementation study in Malawi in 2021 and 2022 to assess the impact of an open fracture intervention bundle, including a national education course for clinical officers and management guidelines for open fractures. We recruited 287 patients with open tibia fractures. The primary outcome was a before-and- after comparison of the self-reported short musculoskeletal function assessment score, a measure of patient function. Secondary outcomes included clinical management; and clinician knowledge and implementation evaluation outcomes of 57 health-care providers attending the course. We also constructed multilevel regression models to investigate associations between clinical knowledge, patient function, and implementation evaluation before and after the intervention. Findings The median patient function score at 1 year was 6.8 (interquartile range, IQR: 1.5 to 14.5) before intervention and 8.4 (IQR: 3.8 to 23.2) after intervention. Compared with baseline scores, we found clinicians' open fracture knowledge scores improved 1 year after the intervention was implemented (mean posterior difference: 1.6, 95% highest density interval: 0.9 to 2.4). However, we found no difference in most aspects of clinicians' open fracture management practice. Conclusion Despite possible improvement in clinician knowledge and positive evaluation of the intervention implementation, our study showed that there was no overall improvement in clinical management, and weak evidence of worsening patient function 1 year after injury, after implementation of the open fracture intervention bundle. Abstracts in [phrase omitted], Francais, [phrase omitted] and Espanol at the end of each article. [phrase omitted] Objectif Evaluer l'Impact d'un ensemble d'interventions relatives aux fractures ouvertes sur la prise en charge clinique et la sante des patients adultes souffrant d'une fracture ouverte du tibia au Malawi. Methodes Afin d'evaluer cet impact, nous avons mene une etude dans le pays en 2021 et 2022, avant et apres la mise en oeuvre, qui prevoyait un cours d'education national destine aux responsables cliniques et des directives de prise en charge des fractures ouvertes. Nous avons recrute 287 patients presentant des fractures ouvertes du tibia. Une comparaison avant/apres de la courte note d'evaluation de la fonction musculosquelettique autodeclaree, qui permet de determiner a quel point le patient est operationnel, constituait le critere d'evaluation principal. Les criteres d'evaluation secondaires incluaient la prise en charge clinique, ainsi que les resultats de l'evaluation des connaissances cliniques et de la mise en oeuvre pour 57 prestataires de soins de sante ayant participe au cours. Nous avons egalement elabore des modeles de regression multiniveaux en vue d'examiner les liens entre les connaissances cliniques, le degre operationnel du patient et l'evaluation de la mise en oeuvre avant et apres l'intervention. Resultats La note mediane de la fonction des patients a un an s'elevait a 6,8 (ecart interquartile, EI: 1,5 a 14,5) avant l'intervention et a 8,4 (EI: 3,8 a 23,2) apres l'intervention. En la comparant avec les notes initiales, nous avons decouvert que les connaissances des medecins en matiere de fractures ouvertes s'etaient ameliorees un an apres le deploiement de l'intervention (difference moyenne a posteriori: 1,6, intervalle de densite le plus eleve a 95%: 0,9 a 2,4). Toutefois, en ce qui concerne la prise en charge des fractures ouvertes par les medecins, nous n'avons observe aucune difference pour la plupart des aspects. Conclusion Malgre une possible amelioration des connaissances medicales et une intervention dont la mise en oeuvre a ete jugee positive, notre etude a montre qu'il n'existait aucune amelioration globale de la prise en charge clinique et peu d'elements indiquant une degradation de l'etat du patient un an apres sa blessure une fois que l'ensemble des interventions relatives aux fractures ouvertes a ete adopte. [phrase omitted] Objetivo Evaluar el Impacto de un paquete de Intervencion en fracturas abiertas sobre el manejo clinico y los resultados de los pacientes adultos en Malawi con fracturas abiertas de tibia. Metodos Se realizo un estudio de implementacion antes y despues en Malawi entre 2021 y 2022 para evaluar el impacto de un paquete de intervencion en fracturas abiertas, que incluye un curso nacional de educacion para funcionarios clinicos y directrices de manejo para fracturas abiertas. Se reclutaron 287 pacientes con fracturas abiertas de tibia. El resultado primario fue una comparacion antes y despues del puntaje breve de evaluacion de la funcion musculoesqueletica autoinformada, una medida de la funcion del paciente. Los resultados secundarios incluyeron: el manejo clinico; y los resultados de la evaluacion del conocimiento clinico y la implementacion de 57 profesionales sanitarios que asistieron al curso. Tambien se construyeron modelos de regresion multinivel para investigar las asociaciones entre el conocimiento clinico, la funcion del paciente y la evaluacion de la implementacion antes y despues de la intervencion. Resultados El puntaje medio de la funcion del paciente a un ano fue de 6,8 (rango intercuartilico, IQR: 1,5 a 14,5) antes de la intervencion y de 8,4 (IQR: 3,8 a 23,2) despues de la intervencion. En comparacion con los puntajes iniciales, se observo que los puntajes de conocimiento de fractura abierta de los medicos mejoraron un ano despues de la implementacion de la intervencion (diferencia posterior media: 1,6; intervalo de densidad mas alta del 95%: 0,9 a 2,4). Sin embargo, no se observaron diferencias en la mayoria de los aspectos de la practica clinica para el manejo de las fracturas abiertas. Conclusion A pesar de la posible mejora de los conocimientos de los medicos y de la evaluacion positiva de la implementacion de la intervencion, nuestro estudio mostro que no hubo una mejora general en el manejo clinico y pruebas debiles de empeoramiento de la funcion del paciente un ano despues de la lesion tras la implementacion del paquete de intervencion en fracturas abiertas., Introduction Economic growth, urbanization and increased road vehicle use have led to a rapid rise in the rates of road traffic incidents in low-income countries. (1) Open fractures are increasingly [...]

We present the case of a 44-year-old patient who crushed her ring finger in a door 4 months earlier. She was treated in the community for her chronic fingertip wound/pyogenic granuloma. As the lesion was not healing with regular wound management she was eventually referred to secondary care for an opinion. She underwent immediate excisional biopsy with safe margins for tissue diagnosis and had histological confirmation of an advanced malignant melanoma. The staging head, neck, thorax, abdomen and pelvic CT showed lymph node enlargement and widespread metastatic lesions. Our case shows how if hand lesions are not resolved following trauma, the patient needs to be assessed for unusual pathologies and, if necessary, or in doubt, referred to the specialists. [ABSTRACT FROM AUTHOR]

Background: Open fractures, a common consequence of road traffic collisions, are associated with a high risk of complications. The introduction of standard guidelines has been shown to improve patient care and reduce the risk of complications in several countries. In September 2021, the Malawi Orthopaedic Association/Arbeitsgemeinschaft für Osteosynthesefragen Alliance (MOA/AOA) guidelines and standards for open fracture management were introduced in Malawi. This study aimed to assess the management of open fractures in hospitals in Malawi, before and after implementing a training course on the MOA/AOA open fracture guidelines., Methods: This was a descriptive and quantitative, before-and-after study that reviewed the medical files of patients with open fractures at Zomba Central Hospital and Mulanje, Salima, and Mangochi district hospitals over two 3-month periods. Variables included initial assessment; antibiotic prophylaxis; place of debridement; type of anesthesia; treatment of the open fracture in the emergency department, operating room, and wards; and short-term complications requiring hospital treatment., Results: A total of 88 open-fracture case files were reviewed; 43 were prior and 45 were subsequent to the implementation of the open fracture guidelines. The overall median patient age was 36 years (interquartile range, 27 to 45 years), and 91% (80) were male. Limb neurovascular status assessment and documentation improved from 26% (11) of the patients before the guidelines to 62% (28) afterward (p = 0.0002). The percentage who underwent debridement in the operating room significantly increased from 19% (8) to 69% (31) (p = 0.01). The percentage who underwent debridement under general or spinal anesthesia significantly increased from 5% (2) to 38% (17) and from 12% (5) to 29% (13), respectively (p= 0.001). The wound infection rate decreased from 21% to 11%, but this was not significant, and there was no change in the overall complication rate (p = 0.152)., Conclusions: This study suggests that training on the MOA/AOA open fracture management guidelines followed by their implementation can lead to at least temporary improvement in the management of open fractures. Nevertheless, additional studies need to be performed to understand the effect on long-term patient outcomes., Levels of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This research was funded by the AO Alliance, AO Trauma. The Article Processing Charge for open access publication was funded by the Wellcome Trust (grant no. 203919). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A613)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)