Assessing the Burden of Operatively Managed Extremity Fractures in Malawi: A Tale of Two Tertiary Hospitals.

BACKGROUND

Low- and middle-income countries (LMICs) account for 90% of all deaths from injury globally, yet health systems remain poorly equipped to manage the escalating trauma burden.

PURPOSE: This study describes the prevalence, causes, and surgical management of extremity fractures at Malawi's two high-volume tertiary hospitals.

METHODS

A prospective cross-sectional observational study collected injury mechanism and injury type as well as operative data on all patients undergoing surgical management of upper and lower extremity fractures at Queen Elizabeth Central Hospital (QECH) and Lilongwe Institute of Orthopedics and Neurosurgery (LION) Trust Hospital between January 2023 and March 2025. Descriptive statistics characterized study data, and ordered logistic regression evaluated factors associated with injury severity.

RESULTS

Details were recorded for 5674 patients and operations, comprising 79% males. Motorcycle collisions accounted for 35% of injuries, followed by falls (18%) and pedestrian-related road traffic collisions (15%). One quarter of patients presented with open fractures, with higher proportions at QECH than at LION (30% vs. 22%, p = 0.001). The median time from admission to surgery was 7 days (interquartile range 1-18). Consultants performed 80% of surgeries at LION but only 16% at QECH (p < 0.001).

CONCLUSIONS

This study highlights a critical and escalating operative trauma burden in Malawi, driven largely by road traffic injuries, particularly motorcycle taxis. The high prevalence of open fractures, surgical delays, and workforce disparities underscore the urgent need for coordinated health system reforms, including strengthening surgical infrastructure, expanding specialist training, and implementing evidence-based road safety interventions.

LEVEL OF EVIDENCE: Level IV, Prognostic Study.