The burden of long bone fracture and health system response in Malawi: A scoping review

Fractures pose serious health and socioeconomic consequences for individuals, their families, and societies more broadly. In many low-resource settings, case fatality and long-term sequelae after a fracture remain high due to individual- and system-level barriers affecting timely access to care. This scoping review explored the burden of fractures in Malawi using long bone fracture (LBF) as a case study by examining the epidemiology of these injuries, their consequences, and the accessibility of quality healthcare. Our aim is to not only describe the scale of the issue but to identify specific interventions that can help address the challenges faced in settings with limited resources and healthcare budgets.

A scoping review methodology was adopted with a narrative synthesis of results. We searched five databases to identify relevant literature and applied the "Three Delays" model and the WHO's Building Blocks Framework to analyse findings on the accessibility of fracture care.

Fractures most often occurred among young males, with falls being the leading cause, constituting between 5 and 35 % of the total burden of injuries. Fractures were typically managed without surgery despite consistent local evidence showing surgical treatment was superior to conservative management in terms of length of hospital stay and bone healing. Poor functional, economic, and social outcomes were noted in fracture patients, especially after conservative treatment. A lack of trust in the health system, financial barriers, poor transport, and road infrastructure, and interfacility transfers were identified as barriers to care-seeking. Factors challenging the provision of appropriate care included governance issues, poor health infrastructure, financial constraints, and shortage of supplies and human resources.

To the best of our knowledge, this review represents the first comprehensive examination of the state of LBF and the health system's response in Malawi. The findings underscore the pressing need for a national trauma registry to accurately determine the actual burden of injuries and support a tailored approach to fracture care in Malawi. It is further evident that the health system in Malawi must be strengthen across all six building blocks to address obstacles to equitable access to high-quality fracture care.