High morbidity and mortality after lower extremity injuries in Malawi: A prospective cohort study of 905 patients.

Introduction
A lower extremity injury can be a devastating event in low-income countries due to limited access to surgical care. Its incidence, treatment patterns, and outcomes, however, have not been well-described.

Methods
We prospectively enrolled all patients admitted with lower extremity trauma to a tertiary hospital in Lilongwe, Malawi between October 2010 and September 2011. Patients with a lower extremity injury but primarily admitted for unrelated reasons were excluded. The outcomes were deaths, complications, and length of hospital stay.

Results
Of the 905 patients eligible for analysis, 696 (77%) were males. Most patients had femur fractures (46%), and most were treated non-operatively (70%). Overall mortality rate was 3.9%. For adult patients with femur fractures, mortality was higher in patients treated with traction (9.0%) than for those treated with surgery (1.3%). The total complication rate was 15%, with adjusted odds of developing a complication higher in patients with concurrent head injury (OR = 2.8; 95% CI: 1.3–6.0), and patients who had an operative treatment (OR = 2; 95% CI: 1.2–1.9). The median length of stay was 16 days (IQR: 6–27) and was greatest among patients with femur fractures.

Conclusion
Lower extremity injuries resulted in substantial mortality and morbidity in this low-income country. Mortality was particularly high among patients with femur fractures who did not have surgery. Modern orthopedic trauma surgery is greatly needed in low-income countries.