Shravya Kakulamarri

ObjectivesTo determine the epidemiology, management patterns, and barriers to care for proximal femoral fractures at three central hospitals in Malawi, a low-income country.DesignProspective cross-sectional study with expert post hoc review.SettingThree central referral hospitals in Malawi, Central Hospital A, B, and C (CHA, CHB, and CHC respectively), over a 15-week period.Patient Selection CriteriaAdult patients (n=152) presenting with proximal femoral fractures were enrolled and followed through their hospitalization.Outcome Measures and ComparisonsFracture care delivered by local orthopaedic teams was recorded. Clinical, demographic, and injury data were collected. An international team of orthopaedic trauma surgeons performed blinded post hoc radiographic assessment. Proportion of fractures treated operatively, concordance between actual and expert-recommended care, and barriers to operative management were compared.ResultsAmong 152 patients (mean age 57 years; 74% male), 61% were managed nonoperatively. Operative rates varied by hospital (CHA 49%, CHC 25%, CHB 8%, p<0.01) but not by fracture type (femoral neck (31B) 40%, intertrochanteric (31A) 35.5%, subtrochanteric (32.XX.1) 42.5%; p=0.761). Multivariable analysis controlling for hospital demonstrated that age ≥65 years was independently associated with 99% lower odds of surgery (adjusted odds ratio 0.01, 95% confidence interval: 0.002–0.06). There was poor agreement between actual treatment delivered locally and treatment recommended by the international reviewers (Cohen’s Kappa = 0.0), with international reviewers recommending surgery for nearly all fractures. Local providers most commonly cited limited resources (N=54, 59%), equipment shortages (N=31, 34%), and inadequate facilities (N=12, 13%) as barriers.ConclusionsMost hip fractures in Malawi were managed nonoperatively due to health system constraints, which may result in poor outcomes. Operative rates varied widely across hospitals, and older adults were disproportionately excluded. Standardized referral and treatment protocols, strengthened surgical infrastructure, and targeted resource allocation are urgently needed.

Orthopaedic and related care has the potential to present unique obstacles for patients with a range of autism manifestations. In this review, we aim to describe and analyze the literature on autistic patients’ experience within orthopaedics and closely related fields. This literature search utilized the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases. Three major concepts were built into the search terms: (1) patients on the autism spectrum; (2) patient experience; and (3) movement sciences, including orthopaedics, physical medicine and rehabilitation (PM&R), occupational therapy (OT), and physical therapy (PT). Our search yielded 35 topical publications, with the major topic areas addressed as follows: (1) clinical and perioperative management, (2) therapy interventions, (3) participation in exercise and social play, (4) sensory management and accommodations, (5) caregiver/parent training and involvement in care, (6) healthcare needs and barriers to care, and (7) utilization of technology. In the current literature, there are no studies that attempt to directly assess autistic patient experience with care practices and clinical environments in orthopaedics. Rigorous, direct examination of the experience of autistic patients within clinical orthopaedic settings is urgently needed to address this gap.