Paediatric fracture complications following traditional bone setting in low- and middle-income countries: a systematic review and meta-analysis protocol.

INTRODUCTION AND AIMS: Traditional bone setters (TBS)-lay practitioners who manage fractures without formal medical qualification-treat an estimated 10%-85% of fracture patients in low- and middle-income countries (LMICs). Children are disproportionately vulnerable due to physeal immaturity and lower diastolic blood pressure thresholds that increase susceptibility to compartment syndrome at lower absolute intracompartmental pressures than in adults. No prior systematic review has restricted analysis exclusively to the paediatric population or generated pooled meta-analytic estimates of complication rates. This protocol describes a systematic review and meta-analysis to determine the pooled incidence of paediatric TBS-related complications across LMICs.

METHODS AND ANALYSIS: Nine databases will be searched (PubMed/MEDLINE, Embase, Cochrane CENTRAL, African Index Medicus, Global Health/CABI, Scopus, LILACS, WHO ICTRP and the COSECSA Archive) supplemented by grey literature sources, using three complementary PubMed search strings and 15 verified vernacular synonyms for TBS practitioners (including Wegesha, Onisegun, Rebouteux, Huesero and Vaidya). Database searching commenced in April 2026 and is currently in progress. No screening, data extraction or analysis has been initiated. Eligibility requirements: children aged <18 years; confirmed TBS exposure; fracture of any long bone or periarticular region; LMIC setting (World Bank 2024 classification); primary data collected from January 2010 to February 2026; and quantitative reporting of at least one primary outcome. Studies reporting mixed-age populations are eligible only if a paediatric subgroup (0-17 years) is extractable in absolute numbers. Title and abstract screening will be performed independently by YeMK and YoMK; discrepancies will be resolved by HB.Primary outcomes are: major limb amputation, bonesetter's gangrene, Volkmann's Ischaemic Contracture (VIC) and sepsis-related mortality. Risk of bias will be assessed using the Newcastle-Ottawa Scale (NOS), MinCir scale and Mixed Methods Appraisal Tool (MMAT). Pooled complication proportions will be calculated using the Freeman-Tukey double arcsine transformation under a random-effects model (DerSimonian-Laird and REML). Lag time from injury to hospital presentation will be examined as a continuous moderator in meta-regression, and the certainty of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION: No primary data are collected; formal ethics approval is not required. Findings will be disseminated through peer-reviewed publication and presentation at relevant orthopaedic and global surgery conferences. If pooled paediatric amputation rates exceed 30% in late-presenting patients, findings will additionally be submitted as a formal evidence brief to the WHO Global Surgery Programme, the College of Surgeons of East, Central and Southern Africa Global Surgery Commission, and national orthopaedic associations in Nigeria, Ghana, Ethiopia and Pakistan. This protocol is registered with PROSPERO (CRD420261349595).

PROSPERO REGISTRATION NUMBER: CRD420261349595.