Time-to-Surgery in Orthopedic Trauma Across Sub-Saharan Africa: A Scoping Review

Trauma is a leading cause of morbidity and mortality worldwide and disproportionately burdens low- and middle-income countries (LMICs) [1]. Sub-Saharan Africa (SSA) faces an escalating trauma epidemic, with the incidence of mortality following traumatic injuries surpassing that of HIV/AIDS, malaria, and tuberculosis combined. Orthopedic trauma constitutes a significant portion of this burden, often resulting in severe disabilities that hinder economic productivity and quality of life. Despite accounting for only half of the world’s vehicles, LMICs experience 90% of global road traffic deaths, contributing significantly to the rising orthopedic trauma caseload [2]. However, limited capacity for timely and effective orthopedic trauma care continues to drive preventable complications, lasting disability, and premature mortality.

One of the critical challenges in orthopedic trauma management in SSA is the delay in surgical treatment. These delays stem from systemic barriers, including a shortage of orthopedic surgeons, inadequate trauma facilities, and disparities between urban and rural healthcare infrastructure [3]. The World Health Organization has identified a severe global shortage of surgical providers, with the gap being particularly pronounced in LMICs [4]. In SSA, prolonged waiting times for definitive orthopedic trauma care are driven by insufficient operating rooms and ICU spaces, a limited number of trained surgical providers, and restricted access to orthopedic equipment. These challenges result in significant delays in surgical intervention, leading to increased complications and poor patient outcomes. Delays in receiving surgical care were found to be the largest contributor to preventable trauma deaths (59%), underscoring the urgent need for systemic improvements [5].

The consequences of delayed orthopedic trauma surgery extend beyond immediate health outcomes. Poorly managed trauma can lead to permanent deformities, functional impairments, and psychosocial challenges that diminish patients’ quality of life and economic productivity [4]. Furthermore, the absence of standardized trauma registries in much of SSA has made it difficult to systematically assess time from injury to definitive treatment, highlighting a significant gap in data-driven policy-making [5]. Tackling the trauma epidemic in SSA demands a comprehensive approach that targets both systemic and structural barriers to timely and effective care.

This scoping review aims to investigate the current landscape of timely orthopedic trauma surgery in SSA, exploring the contributing factors and their broader implications. By synthesizing existing evidence, this review seeks to inform future strategies to improve surgical efficiency, optimize trauma care delivery, and ultimately reduce the burden of preventable disability and death in the region.

Literature Search

This scoping review follows the guidelines in accordance with the PRISMA statement (extension for Scoping Review) and follows the framework established in Arksey and O’Malley [6, 7]. A preliminary literature search investigating time to orthopedic trauma surgeries in Sub-Saharan African populations informed the decision to conduct a scoping review as the most appropriate approach to map existing evidence, identify key themes, and highlight areas requiring further investigation. A protocol was created and a comprehensive search in the PubMed, Cochrane, Web of Science, African Index Medicus, and Global Health Journal databases was conducted for English-language studies that involve orthopedic trauma surgeries in Sub-Saharan Africa. The search terms used in this search are listed in Table 1.

Study Eligibility criteria

Inclusion criteria consisted of studies containing patients who underwent orthopedic trauma surgeries, reported “time to surgery” outcomes and were conducted in Sub-Saharan Africa. All eligible papers were published in the English language between January 2010 and January 2025 and comprised of level evidence I-IV. Animal studies, studies without surgical intervention, and studies published before 2010 were excluded. Time-to-surgery outcomes were extracted when a surgical intervention was performed and when studies reported intervals including time from injury to admission, time from admission to surgical intervention, or time from injury to surgical intervention.

Orthopedic trauma is defined as any injury caused by some external force, such as a severe fall, a serious accident, or even a violent attack [8]. Orthopedic injuries are defined as injuries to anatomical structures of the musculoskeletal system, including bones, cartilage, joints, ligaments, muscles, and tendons. Common injuries include but are not limited to bone fractures, ligament tears, tendon tears, and joint dislocations. Given the overlap between orthopedic trauma and neurotrauma, spine cases were included if they involved vertebral fractures, spinal stabilization, or procedures performed by orthopedic surgeons. Cases with primary spinal cord injury or isolated neurosurgical decompressions without bony fixation were excluded unless orthopedic intervention was documented. Additionally, complex trauma cases, such as high-energy injuries with both orthopedic and neurological involvement were considered if orthopedic stabilization was a primary component of surgical management.

Study Selection and Data Extraction

Following the database search, two independent reviewers (L.F. and M.L.) screened the titles of all retrieved articles using the pre-established inclusion and exclusion criteria. Articles that passed title screening underwent abstract screening, followed by full-text review. After each stage, the reviewers compared their lists of included and excluded articles. Conflicts were resolved through independent re-review and discussion. In studies that reported on non-SSA countries, only data pertaining to SSA patients were reported.

Final data extraction was performed independently by multiple team members (L.F. and M.L.) using a standardized Excel spreadsheet stored on a secure server. Extracted data included study characteristics, population demographics, type and timing of surgical intervention, and reported outcomes. Time data were pooled and subsequently categorized based on the natural intervals that emerged within the dataset. Barriers to timely surgery were extracted from the results and discussion sections of each included study, based solely on factors reported as inherent to that study. All data used in this study was secondary data and do not represent direct policy prescriptions for any individual country or institution. Collaboration with local partners was explored to ensure contextual relevance and cultural sensitivity in interpreting the findings. Descriptive statistics were used to summarize study characteristics, and qualitative synthesis was performed to identify recurring themes, patterns of delay, and contributing factors affecting access to timely orthopedic trauma care.

A total of 1,149 studies were identified and screened in the initial search (Figure 1). Forty-four studies (3.8%) met the inclusion criteria and were analyzed in this review (Table 2). Two Level I studies, 17 Level II studies, 12 Level III studies, and 13 Level IV studies were included. Three studies were comparative in design, while 41 were non-comparative.

Study Demographics

A total of 8,116 patients, of whom 5,361 identified as male and 2,706 identified as female, and 8,132 injuries were included across the studies; one study did not report sex distribution. The age of participants ranged from 5.2 to 75.8 years, with a mean age of 34.9 ± 13.2 years. Seventeen countries across SSA were represented in this review (Table 3, Figure 2), with the number of studies per country ranging from 1 to 11. Twenty-six studies reported on East Africa, 10 studies reported on West Africa, 5 studies reported on Southern Africa and 3 studies reported on Central Africa. Two studies included participants from multiple countries. The highest representation was from Tanzania (11 studies), followed by Ethiopia (8 studies), and Uganda (5 studies).

Mechanism of Injury

Of the 44 included studies, 36 studies (5,056 patients) reported mechanisms of injury, while the remaining 8 studies (3,060 patients) did not (Figure 3). Road traffic accidents were the most common mechanism, reported in 31 studies (3,312 patients), and included motorcycle accidents (12 studies), pedestrian injuries (11 studies), and general motor vehicle accidents (12 studies). Falls were reported in 23 studies, with 122 patients falling from height and 711 patients falling from standing height. Other mechanisms included gunshot injuries (337 patients), assaults (427 patients), sports injuries (84 patients), military-related injuries (8 patients), and work-related trauma (55 patients). Crush injuries, lacerations, burns, animal-related trauma, and electrical injuries were also reported but were less common than the previously mentioned mechanisms of injury.

Orthopedic Trauma Injury & Surgical Intervention

Femoral and tibial fractures were the most frequently reported injuries. Femoral fractures were described in 19 studies, including femoral shaft fractures (7 studies), proximal femur fractures (4 studies), and unspecified femoral fractures (3 studies). Tibial fractures were reported in 17 studies, comprising tibial shaft fractures (8 studies), distal tibial fractures (2 studies), proximal tibial fractures (1 study), and unspecified tibial fractures (3 studies). Spinal injuries were described in 7 studies, including cervical (6 studies), thoracic (5 studies), and lumbar (5 studies) regions. Less frequently reported injuries included knee ligamentous injuries (1 study) and supracondylar humeral fractures (1 study). Eight studies reported musculoskeletal fractures, dislocations, or other injuries without further specification.

Surgical management was reported across multiple studies, with open reduction and internal fixation (ORIF) being the most frequently described intervention (31 studies). Intramedullary nailing was reported in 23 studies, plating and screw fixation in 10 studies, and external fixation in 12 studies. Less commonly reported procedures included percutaneous pinning with K-wires (2 studies), ligamentous repair (1 study), tendon repair (2 studies), hemiarthroplasty (3 studies), amputation (3 studies), and skeletal traction (3 studies). Spinal procedures, including laminectomy, fusion, and discectomy with fusion, were reported in 11 studies. Notably, 8 studies reported surgical interventions without specifying the procedure.

Time to Surgical Intervention

Time to treatment was inconsistently reported across studies, with intervals measured from injury to admission, admission to surgery, or injury to surgery (Table 4). Of the included studies, 22 reported injury-to-admission times, 24 reported admission-to-surgery times, and 25 reported injury-to-surgery times. Four studies reported at all three intervals, while 14 studies reported both injury-to-admission and admission-to-surgery times. Eleven studies reported patient populations with multiple time intervals, including 5 for injury-to-admission, 5 for admission-to-surgery, and 1 for injury-to-surgery. Across studies, injury-to-admission intervals were frequently within 24 hours of the injury. In contrast, time from admission to surgery was highly variable, with most patients receiving operative management several days to weeks after injury.

Time from Injury to Admission

Twenty-two studies reporting time from injury to admission, however 5 studies presented multiple time intervals that could not be isolated (Table 4). In the remaining 17 studies, 10 (58.8%) reported that most patients were admitted within 24 hours of injury. A cluster of 5 studies described delays of 48 to 72 hours, indicating that access to hospital care is not always immediate, while prolonged delays beyond 3 days were rarely reported (1 study).

Time from Admission to Surgery

Of the 24 studies reporting time from admission to surgery, 5 presented multiple time intervals that could not be isolated (Table 4). Among the remaining 19 studies, 8 reported early surgical intervention within 24 hours of admission across the 7 days to 1 month, and 1 at >1-month post-admission.

Time from Injury to Surgery

Twenty-five studies reporting time from injury to surgery, with only 1 study reporting multiple time intervals that could not be isolated (Table 4). Of the remaining 24 studies, only a few studies (3/24; 12.5%) reported that most patients underwent surgery within 24 hours of injury. Two studies reported surgery at 48-72 hours, while 16 studies (66.7%) reported delays of more than 7 days to 1 month and 3 studies (12.5%) reported delays exceeding 1 month.

Barriers to Treatment

Multiple studies identified barriers contributing to delays in surgical intervention (Figure 4). The most frequently reported barriers were financial costs (23 studies), lack of surgical equipment (21 studies), and limited operating room availability (19 studies). Other commonly reported barriers included limited numbers of operative personnel (14 studies), too few surgeons to meet workload demands (13 studies), lack of imaging equipment (12 studies), suboptimal pre-hospital medical services (11 studies), and lack of hospital resources (10 studies).

Specific imaging deficiencies included shortages of fluoroscopy units (4 studies), X-ray machines (3 studies), and insufficient numbers of trained imaging personnel (1 study). Transportation limitations were reported in 12 studies, often related to long distances to hospitals. Delays associated with traditional bone-setter treatment were reported in 5 studies. Among studies reporting financial barriers, issues included inability to pay for initial treatment (3 studies), inability to pay for implants (1 study), and insurance-related challenges (3 studies). Less commonly reported barriers included ineffective ambulance systems (8 studies), incomplete or inefficient patient chart systems (3 studies), and other isolated factors such as conflict-related disruptions (1 study).

This scoping review analyzed 44 studies, encompassing 8,116 patients with 8,132 orthopedic injuries across 17 SSA countries. East Africa was the most represented region, including Tanzania, Ethiopia, and Uganda. Most patients represented in this review were male and under 40 years old, reflecting the continent’s young labor force and those most engaged in high-risk occupations [9, 10, 11]. Disability is a major consequence of orthopedic injuries in SSA, with 61% of patients in one study reporting persistent functional limitations one year after injury and only 59% of these patients returning to work [12]. These long-term impairments carry profound social and economic consequences, often limiting individuals’ ability to work, provide for their families, and fulfill caregiving responsibilities. Beyond physical limitations, patients experience psychological and social burdens, including stress, isolation, and reduced participation in community life [13]. Rapid urbanization, chaotic industrialization, and the expansion of domestic markets further increase exposure to injury and place strain on an already overburdened healthcare system [5, 14, 15]. This demand, combined with gaps in care, fuels a cycle where injuries overwhelm health systems, leading to disability that reinforces social and economic burdens on patients and healthcare providers.

Road traffic accidents (RTAs) were the most frequently reported mechanism of orthopedic trauma, reported in 31 studies and encompassing 3,312 patients.  While global road traffic deaths declined by 5% in 2021, nearly 250,000 individuals in SSA lost their lives in road traffic crashes with another 42 million individuals experiencing some type of musculoskeletal injury this year alone [16]. Rapid motorization without corresponding improvements in infrastructure, enforcement, or emergency care has fueled a disproportionate burden of transport-related trauma [17]. In this study, the predominance of femoral shaft and tibial shaft fractures aligns with the high rates of road traffic collisions in Sub-Saharan Africa, while the frequent involvement of the spine reflects the devastating consequences of both vehicular trauma and falls in unsafe labor settings. Falls represented the second most common etiology, with 833 patients affected, reflecting occupational hazards and unsafe labor practices [18]. Of workers in Ethiopia who sustained a spine injury at work, 80.7% were performing unsupervised labor and 85.3% had never received safety training prior to starting work [19]. Violence-related mechanisms, including 337 gunshot injuries and 427 assault-related injuries, highlight the impact of sociopolitical instability, communal clashes, and military conflicts, often compounded by the absence of prehospital emergency services [20, 21]. Reducing these injuries will require decisive action to strengthen road safety, enforce traffic laws, improve workplace protections, expand emergency care, and combat violence at the community level.

The interval from injury to hospital admission is a critical determinant of trauma outcomes and provides a window into the strengths and weaknesses of health systems, highlighting where targeted improvements are needed. While many patients, particularly in urban areas, are able to access care within 24 hours, this does not reflect the challenges faced in rural or underserved regions. A substantial subset of patients experience delays of 48 to 72 hours or longer, with rare cases extending beyond a week, underscoring systemic and infrastructural barriers rather than the clinical severity of their injuries. Limited prehospital services, overburdened ambulance networks, poor road infrastructure, and long travel distances are recurring constraints, leaving many patients dependent on informal transport that prolongs access to timely treatment [5, 22, 23]. Rural patients face particularly stark disadvantages, with longer travel times, scarce surgical capacity, and higher mortality compared to their urban counterparts, while urban centers are often strained by overwhelming patient loads and restricted operating theater availability, making it difficult for providers to provide timely interventions [24, 25]. Cultural practices further exacerbate these challenges: traditional bonesetters frequently serve as the first point of care, delaying definitive hospital treatment until complications emerge [26, 27, 28, 29]. Patients may cycle through multiple providers, often due to failed interventions, before reaching a tertiary facility for treatment [26, 27, 28, 29]. Time to admission is not just a measure of delay but a marker of equity, shaped by transport, emergency capacity, cultural practices, and health system priorities. Reducing these delays depends on stronger trauma networks, expanded rural surgical services, and greater trust in biomedical care; without these changes, preventable morbidity, mortality, and disability will persist in other low- to middle-income countries around the world.

Surgical delays in Sub-Saharan Africa stem from structural deficits that extend far beyond individual hospital inefficiencies. While some patients underwent surgery within 24 hours, far more experienced multi-day or multi-week delays. Financial obstacles were the most persistent, encompassing treatment costs, implants, and insurance challenges, effectively stratifying access by socioeconomic status. Evidence from Uganda supports this finding, where social capital rather than clinical severity presents as a strong predictor of surgery, illustrating how inequities outside the hospital walls directly determine treatment outcomes [30, 31]. Parallel to these financial barriers are severe shortages in personnel and infrastructure limitations, including limited operating rooms, equipment, imaging, and trained staff, which force clinicians to ration care by feasibility rather than need [31, 32]. Young et al. highlight the Malawian experience, where a rapidly rising femoral fracture burden and stagnant operative capacity illustrate the widening mismatch between demand and available resources [33]. Left unaddressed, this mismatch results in preventable disability and long-term morbidity from otherwise treatable injuries [5, 34, 35]. The absence of modern surgical equipment further constrains treatment options, as intramedullary nailing or external fixation for fracture fixation often cannot be performed, leaving clinicians reliant on conservative management [36]. Sustainable progress will require large-scale investments in training and infrastructure, as well as development of context-specific models of care that adapt to resource scarcity and case volumes that exceed an institution’s capacity.

Barriers to timely surgical intervention in Sub-Saharan Africa have a profound impact on patient outcomes, contributing to prolonged suffering, higher complication rates, and increased disability [5]. Financial constraints, limited availability of surgical equipment, and insufficient operating rooms are among the most frequently reported obstacles, while shortages of trained personnel, imaging resources, and pre-hospital services further exacerbate delays in care [37]. Addressing these challenges requires a multifaceted approach. Financial barriers can be mitigated through insurance reform, subsidies, or cost-sharing initiatives. Shortages in equipment and workforce can be alleviated through targeted training programs and policies that encourage retention of skilled personnel [38]. Systemic inefficiencies, including inadequate health information systems and transportation limitations, demand strategic investment in infrastructure. A critical limitation to progress, however, is the lack of research on trauma care outcomes, particularly regarding long-term functional recovery, which restricts evidence-based policymaking [12, 39]. Increasing awareness of these barriers is an essential first step. Shining a light on these challenges can drive research, inform policy decisions, and mobilize stakeholders toward sustainable improvements in trauma care.

Limitations

Some factors limit the interpretation of this review. Restricting the search to English-language publications likely excluded studies in different languages localized to SSA, narrowing regional representation in the scope of this review. The heterogeneity of the included studies made direct comparisons between SSA nations challenging. Key variables, including time to admission, time to surgery, and the definition of orthopedic trauma, were inconsistently reported, complicating comparisons and synthesis of generalizable conclusions regarding treatment timelines. Selection bias is likely, as patients treated exclusively by traditional healers or who never reached hospital care were not captured, underestimating delays and barriers. The evidence base was heavily weighted toward East Africa, leaving Central and Southern Africa underrepresented. Another limitation is the substantial heterogeneity in how “orthopedic trauma” is defined across studies, with some including broad musculoskeletal injuries, which complicates the interpretation of pooled injury-type data. Finally, while the scoping review design effectively maps fragmented literature, it does not support meta-analysis or causal inference, highlighting the need for more rigorous, regionally diverse research.

Orthopedic trauma in Sub-Saharan Africa is characterized by a disproportionate burden of road traffic injuries, high prevalence of long-bone and spinal fractures, and persistent delays in access to surgical care. The overwhelming variability in time to admission and definitive intervention reflects systemic gaps in trauma infrastructure, compounded by financial barriers, limited surgical capacity, and shortages of essential equipment. Collectively, these findings illustrate not only the urgent clinical needs of trauma patients but also the broader health system challenges that perpetuate poor outcomes in Sub-Saharan Africa. Addressing these barriers through targeted investments in surgical workforce development, infrastructure expansion, and affordable access to essential implants and imaging is critical to advancing trauma care and reducing the morbidity and mortality associated with musculoskeletal injuries in this region.