Improving the Management of Adult Patients with Acute Ankle Fractures in Malawi: An Examination of Providers’ Knowledge and Treatment Strategies

Abstract

Category:Trauma; Ankle; OtherIntroduction/Purpose:The burden of trauma is growing worldwide, especially in low-income countries. In Malawi, ankle fractures are common and may receive inadequate treatment due to limited surgical capacity and provider knowledge of evidence- based treatment guidelines. We sought to examine ankle fracture management in Malawi, identify providers’ knowledge gaps, and address these knowledge gaps in ways that were relevant to the Malawian context.Methods:This study had three phases. First, we performed a baseline assessment of orthopaedic providers’ knowledge of anatomy, injury identification, and ideal treatment methods. Second, we observed providers’ treatment strategies while they cared for adult patients with ankle fractures over a five-week period at a large central hospital. We performed blinded, post-hoc reviews of patient x-rays and compared our treatment recommendations to the plans and rationales of Malawian providers. Third, we implemented an educational course addressing the knowledge gaps we identified, performed pre- and post-course knowledge assessments, and launched a standardized protocol for ankle fracture management in Malawi.Results:In our baseline assessment, we identified significant knowledge gaps in identification of common injuries on x-ray and ideal treatment practices. In our observations of treatment practices, 17/49 patients (35%) met operative criteria based on evidence-based guidelines but did not receive operative treatment by Malawian providers. For 7/17 (41%) of these patients, Malawian providers believed nonoperative treatment was ideal. In our educational course, 51/61 participants (84%) performed better between the pre- and post-course assessments. Overall scores improved from a mean of 66% to 77%, an improvement of 5.2/49 questions (95% CI 3.8-6.6, p<0.001). Providers could identify one more injury correctly out of 6 that were tested (95% CI 0.6-1.6, p<0.001), and identify one more ideal treatment out of 7 (95% CI 0.5-1.4, p<0.001).Conclusion:In Malawi, ankle fractures are common, and most are treated non-operatively. This is partly due to resource limitations, but also due to gaps in provider knowledge and lack of treatment standardization. Here we demonstrated a comprehensive approach to examining the challenges to providing adequate care, as well as the successful implementation of an intervention to improve care capacity nationwide.