Prevalence of neglected long bone fractures and associated factors among patients with musculoskeletal trauma at Mulago National Referral Hospital

Abstract

Background: Neglected long bone fractures, defined as fractures presenting more than four weeks after injury without prior definitive orthopaedic management, are a major cause of preventable disability in low- and middle-income countries. Their burden in Uganda is poorly quantified, and the patient and health-system factors driving prolonged neglect at the Mulago National Referral Hospital (MNRH) have not been systematically described. Objectives: To determine the prevalence of neglected long bone fractures among patients presenting with long bone fractures at Mulago National Referral Hospital (MNRH), and to identify factors associated with prolonged neglect among those patients. Methods: A hospital-based, cross-sectional analytical study with a nested screening component was conducted at the orthopaedic outpatient clinic and accident and emergency unit of MNRH. All long bone fracture patients presenting during the study period were screened and logged to provide the prevalence denominator. Patients meeting the criteria for neglect were enrolled consecutively until the target sample size of 105 was reached. Data were collected using a structured, pre-tested, bilingual (English/Luganda) questionnaire and a focused clinical and radiological assessment. The period prevalence was reported with a 95% confidence interval. Factors associated with prolonged neglect (≥90 days from injury to presentation) among neglected patients were examined using bivariate logistic regression for crude associations and Firth’s penalized logistic regression for the multivariable model, with the final model built by backward elimination. Results: During the study period, 843 patients with long bone fractures were evaluated, of whom105 had neglected fractures, giving a prevalence of 12.5%. The median duration of neglect was 62 days (IQR 38–150), with the majority (70.5%) delaying care for 1–3 months. Young adults experienced longer delays, with 38.9% presenting after 91–180 days, while children and the elderly presented earlier (30–90 days). Despite delays, all participants sought some form of care within the first 28 days, predominantly from traditional bone setters (73.3%), whereas only 26.7% visited local clinics. The tibia/fibula was the most commonly fractured bone (38.1%), with fractures occurring more frequently on the left side (63.8%), mainly in the distal segment (39.0%), and predominantly closed (90.5%). Multivariate analysis identified several factors independently associated with neglected fractures: male sex (AOR = 31.7, P=0.001), alcohol use (AOR = 11.8, P=0.007), residence >10 km from a health facility (AOR = 5.7, P=0.013), lack of prior medical advice (AOR = 6.4, P=0.007), and difficulty accessing orthopaedic care (AOR = 13.2, P=0.001). Conclusion: Neglected long bone fractures are common at MNRH and disproportionately affect young adult men. Prolonged neglect is driven jointly by behavioural factors and by structural and informational barriers within the health system, and universal early contact with traditional bone setters represents the single most promising point of intervention. Targeted public-health messaging, structured engagement with traditional bone setters, expansion of regional orthopaedic capacity, and a dedicated rapid-triage pathway for late-presenting patients at MNRH are urgently needed.