Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: ABJS/C.T. Brighton Workshop on Trauma in the Developing World 24 articles


Update on Road Traffic Crashes

Wahid Al-Kharusi FRCS Road traffic injuries comprise the major share of all injuries globally. Traffic injuries kill 1.2 million people annually and injure 40 times as many, leaving a subsequent number totally disabled. Globally we spend approximately US $500 billion annually. The Middle East encompasses West Asia and North Africa and is very diverse economically, culturally and socially. Prevention and management of road traffic crashes and injuries is difficult. Comparative data are not readily available and therefore developing unified policies is a mammoth task. Implementation of best practices is not uniformly advocated due to socioeconomic and cultural differences. Enforcement of endorsed legislation on road traffic safety is not uniform in the region. Professional staff to combat this pandemic are scarce and it is important that capacity building, knowledge sharing, and increased political will becomes a priority in the region. This paper discusses the problems encountered in the prevention and management of road traffic injuries from the site of injury to rehabilitation and social reintegration. The role of Oman and that of the Bone and Joint Decade in the United Nations on Global Road Safety and its update is highlighted.

The Global Burden of Musculoskeletal Injuries: Challenges and Solutions

Charles Mock MD, PhD, Meena Nathan Cherian MD Musculoskeletal injuries are a major public health problem globally, contributing a large burden of disability and suffering. This burden could be considerably lowered by implementation of affordable and sustainable strategies to strengthen orthopaedic trauma care, especially in low- and middle-income countries. This article summarizes the global burden of musculoskeletal injuries and provides several examples of successful programs that have improved care of injuries in health facilities in low- and middle-income countries. Finally, it discusses WHO efforts to build on the country experiences and to make progress in lowering the burden of musculoskeletal injuries globally.

Topics in Global Public Health

David A. Spiegel MD, Richard A. Gosselin MD, R. Richard Coughlin MD, Adam L. Kushner MD, Stephen B. Bickler MD Deficiencies in the delivery of musculoskeletal trauma care in low- and middle-income countries can be attributed to a variety of causes, all of which can be linked to failure of the health system to deliver the necessary services to prevent death and disability. As such, a “systems” approach will be required to improve the delivery of services. The goal of this review is to familiarize the orthopaedic surgeon with selected topics in public health, including health systems, burden of disease, disability adjusted life year (DALY), cost-effective analysis, and related concepts (eg, met versus unmet need, access, utilization, effective coverage).

Nongovernmental Organizations in Musculoskeletal Care: Orthopaedics Overseas

R. Richard Coughlin MD, MSc, Nancy A. Kelly MHS, Wil Berry MS Injuries are a major worldwide contributor to morbidity and mortality. The negative impact caused by such injuries is disproportionately heavy in developing countries. Such disparities are caused by a complex array of problems, including a lack of physical resources, poor infrastructure, and a shortage of trained health professionals. Overcoming such deficits in care will require the involvement of organizations that can offer broad-based solutions. These organizations must bridge the gap between private and public institutions to establish a systems-based approach to program development and institution-building. They must provide not just an adequate level of care, but a transfer of knowledge that leads to sustainable and cost-effective intervention. Orthopedics Overseas is an example of such an organization. We examine the development of Orthopedics Overseas and describe their interventions in Uganda as a case-study to show the unique position they have to affect change.

Musculoskeletal Training for Orthopaedists and Nonorthopaedists: Experiences in India

Anil Arora MS, Anil Agarwal MS, Panos Gikas MBBS, Apurv Mehra In India, health policies, services, health indices, and medical education are improving despite the country’s enormous population and limited resources. Orthopaedic training in India should be geared to serve the predominantly rural population (72% of total population) living in some 550,000 villages, but unless the basic amenities improve in villages and towns, orthopaedists will remain averse to serving in these areas. Traditional practitioners play an important role in musculoskeletal trauma care in villages and even some town and city areas, and hence cannot be ignored. We suggest a stratified system of orthopaedic training for medical graduates, postgraduates, and paramedics with a well-defined need-based curriculum, and a clear cut division of labor, terms, and conditions to suit the stratified social and demographic structure of India. This stratified system is intended to provide appropriate musculoskeletal trauma care services to the rural population, reduce neglected and mismanaged trauma, consequently avoiding subsequent orthopaedic disability, and reduce the financial burden of managing these cases. This system also intends to prevent overloading of teaching hospitals and apex institutes and ensure availability of subspecialized orthopaedic services in the country at designated centers. Traditional practitioners shall be periodically educated regarding safe orthopaedic practices, which are anticipated to yield improved trauma care services.

Trauma Training for Nonorthopaedic Doctors in Low- and Middle-income Countries

Robert Quansah MD, PhD, Francis Abantanga MD, PhD, FWACS, Peter Donkor MDSc, FWACS Increasingly, nonspecialist Ghanaian doctors in district hospitals are called upon to perform a variety of surgical procedures for which they have little or no training. They are also required to provide initial stabilization for the injured and, in some cases, provide definitive management where referral is not possible. Elsewhere continuing medical education courses in trauma have improved the delivery of trauma care. Development of such courses must meet the realities of a low-income country. The Department of Surgery, Kwame Nkrumah University of Science and Technology developed a week-long trauma continuing medical education course for doctors in rural districts. The course was introduced in 1997, and has been run annually since. The trauma course specifically addresses the critical issues of trauma care in Ghana. It has improved the knowledge base of doctors, as well as their self-reported process of trauma care. Through the process we have learned lessons that could help in the efforts to improve trauma training and trauma care in other low-income countries.

Global Relevance of Literature on Trauma

Shahryar Noordin MD, James G. Wright MD, MPH, FRCSC, Andrew W. Howard MD, MSc, FRCSC The trauma pandemic disproportionately kills and maims citizens of low-income countries although the immediate cause of the trauma is often an industrial export of a high-income country, such as a motor vehicle. Addressing the trauma pandemic in low-income countries requires access to relevant research information regarding prevention and treatment of injuries. Such information is also generally produced in high-income countries. We reviewed two years’ worth of articles from leading orthopaedic and general medical journals to determine whether the scientific literature appropriately reflects the global burden of musculoskeletal disease, particularly that due to trauma. General medical journals underrepresented musculoskeletal disease, but within musculoskeletal disease an appropriate majority of papers were regarding trauma, in particular the epidemiology and prevention of injury. Orthopaedic journals, while focusing on musculoskeletal conditions, substantially underrepresented the global burden of disease due to trauma and hardly consider injury epidemiology and prevention. If orthopaedic surgeons want to maximize their global impact, they should focus on writing about trauma questions relevant to their colleagues in low-income countries and ensuring these same colleagues have access to the literature. Case-based Orthopaedic Wiki Project in China

Zhen-Sheng Ma MD, PhD, Hong-Ju Zhang BS, Tao Yu BS, Gang Ren BS, Guo-Sheng Du BS, Yong-Hua Wang BS Traditional continuing medical education (CME) depended primarily on periodic courses and conferences. The cost-effectiveness of these courses has not been established, and often the content is not tailored to best meet the needs of the students. Internet training has the potential to accomplish these goals. Over the last 10 years, we have developed a Web site entitled “,” based upon the wiki concept, which uses an interactive, case-based format. We describe the development of online case discussions, and various technical and administrative requirements. As of December 31, 2007, there were 33,984 registered users, 9,759 of which passed the confirmation procedures. In 2007, an average of 211 registrants visited daily. The average number of first page clicks was 4,248 per day, and the average number of posts was 70 per day. All cases submitted for discussion include the patient’s complaint, physical examination findings, and relevant images based on specific criteria for case discussion. The case discussions develop well professionally. No spam posting or unauthorized personal advertisement is permitted. In conclusion, online academic discussions proceed well when the orthopaedic surgeons who participate have established their identities.

Injuries in Developing Countries—How Can We Help?: The Role of Orthopaedic Surgeons

Lewis G. Zirkle MD Each year nearly 5 million people worldwide die from injuries, approximately the number of deaths caused by HIV/AIDS, malaria, and tuberculosis combined. Ninety percent of these injuries occur in developing countries and that number is growing. Road traffic accidents account for 1.2 million of these 5 million deaths. For each death from trauma, three to eight more are permanently disabled. Orthopaedic surgeons should consider the victims of this epidemic by using their ability and capacity to treat these injuries. SIGN (Surgical Implant Generation Network, Richland, WA, USA) builds local surgical capability in developing countries by providing training and equipment to surgeons for use in treating the poor. It assists in treating long-bone fractures by using an intramedullary nail interlocking screw system. C-arm imaging, unavailable in many of these hospitals, is not necessary to accomplish interlocking. Surgery is performed primarily by local surgeons who record their cases on the SIGN surgical database. Discussion of these reports provides a means of communication and education among surgeons. This database demonstrates the capability of these surgeons. It also demonstrates that the SIGN intramedullary nail is safe for use in the developing world as it has been successful in treating 36,000 trauma patients.

Soft Tissue Coverage at the Resource-challenged Facility

Tuan Anh Nguyen MD, PhD Covering soft tissue defects remains challenging for orthopaedic surgeons, especially those in resource-challenged facilities. Covering tissue defects follow a plan from simple to complex: primary closure, local flap, area flap, pedicle flap, and free flap. I will limit my discussion to the role of latter two. At the district-level hospital in Vietnam, pedicle flaps are generally more useful, so I will discuss free flaps only briefly. The choices of pedicle flaps include: kite flap, posterior interosseous flap, radial flap (Chinese flap), neurocutaneous flap, anterolateral thigh fasciocutaneous flap, gastrocnemius flap, sural flap, posterior leg flaps; we typically use a free flap with the latissimus dorsi. Soft tissue coverage with pedicle flaps has many advantages: reliability, relatively easy harvest, and good blood supply. Free flaps with microanastomosis have an important place in covering difficult medium- or large-sized soft tissue defects but also require more instruments and more highly trained surgeons.

Musculoskeletal Trauma Service in Thailand

Banchong Mahaisavariya MD Trauma is becoming a leading cause of death in most of the low-income and middle-income countries worldwide. The growing number of motor vehicles far surpasses the development and upkeep of the road and highway networks, traffic laws, and driver training and licensing. In Thailand, road traffic injuries have become the second leading cause of death and morbidity overall since 1990. The lack of improvement to existing roadways, implementation of traffic safety and ridership laws including seatbelt regulations, and poor emergency medical assistance support systems all contribute to these statistics. An insufficient number and inequitable distribution of healthcare professionals is also a national problem, especially at the district level. Prehospital care of trauma patients remains insufficient and improvements at the national level are suggested.

Managing the Injury Burden in Nepal

P. C. Karmacharya MS (oph), G. K. Singh MS, DNB, FICS, MS in Clin Epid, M. P. Singh MS, V. G. Gautam MD, Andrew Par, A. K. Banskota MD, A. Bajracharya MS, A. B. Shreshtha MS, Deepak Mahara MS Nepal loses about 530,000 disability adjusted life years (DALYs) per year to injury, predominantly due to falls. It takes 30,000 Nepali rupees (NR), or approximately US$430 at 70 rupees per $US saved per DALY to achieve primary prevention and 6000 NR per DALY if we invest in hospitals, versus 1000 NR invested in prehospital care, because simpler less expensive actions performed early have a greater impact on outcome than more complex measures later. A system for prehospital services was planned for medical emergencies at a national level meeting at the Medical University of Nepal to promote healthcare to victims in inaccessible regions by empowered or enlightened citizens. Feasible actions for common emergencies were defined and a tutorial required to help the majority of such victims was created and packaged. The knowledge and attitude component of the tutorial will be delivered through a web site to citizens motivated to learn and help with emergencies. The knowledge will be tested through a net-based Multiple Choice Questions (MCQ) test. Practical training in medical triage skills will be provided to those who qualify for the test at the University or its designated affiliates. A mobile phone-based information system will be created and used to make these enlightened citizens available to the victim at the site/time of the emergency.

Musculoskeletal Training for Orthopaedists and Nonorthopaedists in China

Zhen-Sheng Ma MD, PhD, Hong-Ju Zhang BS, Wei Lei MD, PhD, Lu-Yu Huang MD, PhD No diploma for orthopaedic surgery is available in the current medical education and licensing system in China. The orthopaedist generally receives on-the-job training in a clinical practice after getting a license to practice surgery. There are multiple training pathways to and opportunities in orthopaedic surgery, and these vary from hospital to hospital and from region to region. These include on-the-job training, academic visits, rotation through different departments based on local medical needs, fellowship training in large general or teaching hospitals (locally, regionally, nationally, or internationally), English language training, postgraduate diploma training, and Internet CME. Due to the current training system, orthopaedic techniques and skill levels vary greatly from hospital to hospital.

Musculoskeletal Trauma Services in China

Zhen-Sheng Ma MD, PhD, Hong-Ju Zhang BS, Wei Lei MD, PhD, Li-Ze Xiong MD, PhD China is a developing country with a population over 1.3 billion with the second largest group of people in poverty next to India. There are about 159 million motor vehicles, with 163,887,372 drivers. From 2001 to 2004 over 100,000 people died each year in traffic accidents. With law enforcement and public education, traffic accidents have decreased, and the death rate is now less than 100,000 each year.

Providing Outreach Continuing Education in Countries with Limited Resources

Kaye E. Wilkins DVM, MD Obtaining continuing education can be difficult in countries with limited resources. Members of the Pediatric Orthopaedic Society of North America (POSNA) have developed a program for providing outreach continuing education courses in pediatric orthopaedics. POSNA members provide their own transportation to the host country, while the orthopaedic physicians along with the educational institutions in the host country in turn provide the support needed to carry out the courses. They also provide lodging, meals, and local transportation. Since its inception in 1998, 30 courses have been conducted in 19 countries with limited resources. The program has expanded to develop a partnership with the European Pediatric Orthopaedic Society. The protocol for organizing the courses is discussed.

Global Access to Literature on Trauma

Shahryar Noordin MD, James G. Wright MD, MPH, FRCSC, Andrew W. Howard MD, MSc, FRCSC The trauma pandemic disproportionately kills and maims citizens of low-income countries although the immediate cause of the trauma is often an industrial export of a high income country, such as a motor vehicle. Addressing the trauma pandemic in low-income countries requires access to relevant research information regarding prevention and treatment of injuries. Such information is also generally produced in high income countries. We explored various means of making scientific information available to low-income country surgeons using the internet. If orthopaedic surgeons want to maximize their global impact, they should focus on writing about trauma questions relevant to their colleagues in low-income countries and ensuring these same colleagues have access to the literature.

The Practice of Traditional Bonesetting: Training Algorithm

A. B. Omololu MD, S. O. Ogunlade FRCS, V. K. Gopaldasani MBBS Traditional bonesetters (TBS) have been in Nigeria for centuries. Up to 85% of patients with fractures present first to the traditional bonesetters before coming to the hospital and therefore this mode of care delivery cannot be overlooked in Nigeria. We attempted to document the current practice of TBS in Ibadan and their methods of fracture treatment with a view to training and improving the services offered by them. We carried out a literature search to review all previous studies on traditional bonesetters’ practice and visited a few of them to document their current practice. The only change in the management of fractures by the TBS over the past 28 years was the use of spiritual methods of healing to treat open comminuted fractures; a technique for which no scientific basis was readily discernible. There is a need to educate and train the TBS in effective management of both open and closed fractures. Such training should be provided by orthodox orthopedic surgeons with a view to minimizing mismanagement of fractures. To this end, we propose a training algorithm.

Musculoskeletal Training for Orthopaedists and Nonorthopaedists: Experiences in Nepal

Ashok K. Banskota MD, FACS Orthopaedic surgical training in Nepal began in 1998, and four major centers now produce between 15 and 20 graduates annually. The duration of the training is four years in one center and three years in the remaining centers. Trainees have adequate trauma exposure. The major challenges include: tailoring training to suit local needs, avoiding the dangers of market driven orthopaedic surgery, adequately emphasizing and implementing time honored methods of closed fracture treatment, and ensuring uniformity of exposure to the various musculoskeletal problems. Training in research methods needs to be implemented more effectively. The evaluation process needs to be more uniform and all training programs need to complement one another and avoid unhealthy competition. Training for nonorthopaedists providing musculoskeletal care is virtually nonexistent in Nepal. Medical graduates have scant exposure to trauma and musculoskeletal diseases during their training. General surgeons provide the majority of trauma care and in the rural areas, health assistants, auxiliary health workers and physiotherapy assistants provide much needed basic services, but all lack formal training. Traditional “bone setters” in Nepal often cater to certain faithful clientele with sprains, minor fractures etc. A large vacuum exists in Nepal for trained nonorthopaedists leading to deficiencies in prehospital care, safe transport and basic, primary emergency care. The great challenges are yet to be addressed.

Musculoskeletal Trauma Services in Uganda

E. K. Naddumba MMED (Surgery), FCS (ECSA) Approximately 2000 lives are lost in Uganda annually through road traffic accidents. In Kampala, they account for 39% of all injuries, primarily in males aged 16–44 years. They are a result of rapid motorization and urbanization in a country with a poor economy. Uganda’s population is an estimated 28 million with a growth rate of 3.4% per year. Motorcycles and omnibuses, the main taxi vehicles, are the primary contributors to the accidents. Poor roads and drivers compound the situation. Twenty-three orthopaedic surgeons (one for every 1,300,000 people) provide specialist services that are available only at three regional hospitals and the National Referral Hospital in Kampala. The majority of musculoskeletal injuries are managed nonoperatively by 200 orthopaedic officers distributed at the district, regional and national referral hospitals. Because of the poor economy, 9% of the national budget is allocated to the health sector. Patients with musculoskeletal injuries in Uganda frequently fail to receive immediate care due to inadequate resources and most are treated by traditional bonesetters. Neglected injuries typically result in poor outcomes. Possible solutions include a public health approach for prevention of road traffic injuries, training of adequate human resources, and infrastructure development.

Orthopaedic Clinical Officer Program in Malawi: A Model for Providing Orthopaedic Care

Nyengo Mkandawire BMBS, MCh (ORTH), FCS (ECSA), FRCS Eng, Christopher Ngulube BSc (HSE), Christopher Lavy MD, MCh, FRCS Malawi has a population of about 13 million people, 85% of whom live in rural areas. The gross national income per capita is US$620, with 42% of the people living on less than US$1 per day. The government per capita expenditure on health is US$5. Malawi has 266 doctors, of whom only nine are orthopaedic surgeons. To address the severe shortage of doctors, Malawi relies heavily on paramedical officers to provide the bulk of healthcare. Specialized orthopaedic clinical officers have been trained since 1985 and are deployed primarily in rural district hospitals to manage 80% to 90% of the orthopaedic workload in Malawi. They are trained in conservative management of most common traumatic and nontraumatic musculoskeletal conditions. Since the program began, 117 orthopaedic clinical officers have been trained, of whom 82 are in clinical practice. In 2002, Malawi began a local orthopaedic postgraduate program with an intake of one to two candidates per year. However, orthopaedic clinical officers will continue to be needed for the foreseeable future. Orthopaedic clinical officer training is a cost-effective way of providing trained healthcare workers to meet the orthopaedic needs of a country with very few doctors and even fewer orthopaedic surgeons.

Musculoskeletal Trauma Services in Mozambique and Sri Lanka

Richard C. Fisher MD There is currently an escalating epidemic of trauma-related injuries due to road traffic accidents and armed conflicts. This trauma occurs predominantly in rural areas where most of the population lives. Major ways to combat this epidemic include prevention programs, improved healthcare facilities, and training of competent providers. Mozambique and Sri Lanka have many common features including size, economic system, and healthcare structure but have significant differences in their medical education systems. With six medical schools, Sri Lanka graduates 1000 new physicians per year while Mozambique graduates less than 50 from their singular school. To supplement the low number of physicians, a training course for surgical technicians has been implemented. Examination of district hospital staffing and the medical education in these two countries might provide for improving trauma care competence in other developing countries. Musculoskeletal education is underrepresented in most medical school curricula around the world. District hospitals in developing countries are commonly staffed by recently graduated general medical officers, whose last formal education was in medical school. There is an opportunity to improve the quality of trauma care at the district hospital level by addressing the musculoskeletal curriculum content in medical schools.

Musculoskeletal Trauma Services in Serbia

Zoran Vukašinović MD, PhD, Duško Spasovski MD, MSc, Zorica Živković MD, PhD [object Object]