Pediatric Distal Forearm Fractures/Design for Extreme Accessibility in Low Resource Settings

This module allows traditional bone setters, pre-hospital providers, clinical officers, nurses, nurse practitioners, and medical officers to become confident and competent in performing point-of-care ultrasound diagnostic imaging to rule out the presence of a pediatric distal forearm fracture and distinguish between buckle (torus) fractures and cortical break fractures to make appropriate referrals as part of the management of closed pediatric (< 16 years of age) distal forearm fractures in regions without access to X-ray imaging and orthopedic specialist coverage.^{[1][2][3][4][5][6][7][8][9]}

Design for Extreme Accessibility in Low Resource Settings[edit | edit source]

This module applies user-centered, reproducible, and accessible design choices to maximize adoption in resource-constrained settings.

User-Centered Design[edit | edit source]

Traditional bonesetters acquire their skills informally through apprenticeship from relatives.^[10] A 2020 Nigerian feasibility study found that traditional bonesetters recognize their need for formal skills training, are willing to undertake training, and seek formal recognition by the government.

Nurses, clinical officers, and medical officers are formally trained healthcare practitioners who have not received any exposure to diagnostic imaging or orthopedic surgery outside of their undergraduate education.

This module will address user needs by providing competency-based and microcredential training to orthodox and traditional fracture caregivers on fracture diagnosis and safe methods of fracture treatment to improve fracture outcomes in LMICs.

Over 4 billion people do not have access to the Internet.^[11] The penetration of high-speed Internet connectivity (broadband, 3G, or better mobile connections) is less than 30% in rural regions.^[12] Smartphones only make up 50% of total connections in sub Saharan Africa.^[13] 44% of the world's population lives in remote or rural regions.^[14] Over half of Nigeria's population of 206 million people live in rural areas but only 15% of the road networks are paved.^[15]

To promote adoption of this training module in resource-constrained settings, we recommend using a mobile tablet device with the following user-centered design features:

• Wi-fi and cellular connectivity to maximize the ability to receive software updates to the Butterfly App and ensure the Butterfly iQ+ probe is the most up-to-date version
• ruggedized cover to withstand rough handling during transport to and from a rural community,
• tablet stand to permit hands-free use, and
• larger screen area and extended battery life to optimize learning.

Reproducible Design[edit | edit source]

This module does not require access to teachers, animal bones, artificial bones or fracture patients, and uses locally available materials and supplies, and locally made, high-fidelity, 3D printed bone simulation models for point-of-care ultrasound diagnostic, and proper splinting techniques skills training.

All of the module's bone simulation models are open-source, can be digitally manufactured on open-source, open filament desktop 3D printers using low-cost, biorenewable plastic, and are designed to be ready for use right out of the 3D printer.

On-site access to a 3D printer is not required for the learner. Only one 3D printer is required within a country. The open-source 3D files can be emailed to any 3D printing organization anywhere. The 3D printed simulation models can be picked up by the learner or delivered anywhere across the country by motorcycles, all-terrain vehicles, trucks, or airplanes within 1-2 days.

We will publish our self-assessment framework directly in the Appropedia module (instead of a downloadable pdf) to provide automatic translations of the Training Logbooks in multiple languages to learners around the world.

The demand for this module will be greatest in regions with little or no access to the Internet, smartphones, or grid electricity. When possible, we will make as much of the module content (including step-by-step simulator build, simulator use, and self-assessment framework instructions with photos instead of only videos) available in pdf format using Appropedia's export function for offline access.

The primary risk to reproducibility of this module is access to affordable point-of-care ultrasound devices ($2,399 USD) for training and clinical use.^[16] We will be developing local and international private-public partnerships to provide point-of-care ultrasound devices at the lowest cost for traditional bone setters, nurses, midwives, clinical officers, and medical officers in LMICs.

Another risk to reproducibility is that the 3D printed simulators are often locally made from imported plastic filament. If the learner wants to order a large volume of 3D printed models, they should notify their local 3D printing supplier in advance to stock adequate filament.

No tools, specialized equipment, or technical expertise is required to build, install, operate and maintain the simulators within the intended place of use.^[17][18][19]

Our high-fidelity, reusable simulators offer significant value for money in comparison to existing approaches such as costly, reusable, commercial ultrasound phantoms and single-use animal cadaveric bones.^[17][20]

The benefits of making the Point-of-Care Ultrasound Extremity Fracture Simulator locally in Nigeria are the filament and supplies costs are over 35 times cheaper than purchasing a comparable, patented, U.S.-made ultrasound phantom that costs $1,034.80 USD.^[21] By obtaining locally made simulators, the learner also saves on customs dues, processing fees, and international shipping costs that are incurred when using a product that is not made locally.

This module uses simulators built from 3D printed models and connectors locally manufactured from locally produced or imported filament plus readily available materials, supplies, and equipment.

Accessible Design[edit | edit source]

We propose training orthodox and traditional practitioners to use clinical examination and point-of-care ultrasound to diagnose long bone fractures because fracture patients often cannot afford or access X-ray imaging services in LMICs.

When possible, the simulator components are reusable to minimize the use of consumables and maximize their lifespan in the place of use.

Offline and Off Grid Access[edit | edit source]

Self-directed training is typically only available online or via mobile apps. These traditional approaches have accessibility barriers in low resource settings because:

• Over 4 billion people do not have access to the Internet
• The penetration of high-speed Internet connectivity (broadband, 3G, or better mobile connections) is less than 30% in rural regions
• Smartphones only make up 50% of total connections in sub Saharan Africa, and
• An estimated 770 million people worldwide lack access to electricity and 600 million of these individuals reside in sub Saharan Africa.^{[22][23][24][25]}

The demand for this module will be greatest in regions with little or no access to the Internet, smartphones, or grid electricity. Our self-assessment frameworks only require taking photos and not videos. This allows learners to use any cellphone with a camera and not only smartphones. When possible, we have provided images (instead of only videos) so the module content can be available in pdf format using Appropedia's export function for offline access.

Last Mile Implementation[edit | edit source]

We are continuing to develop local and international partnerships to deliver 3D printed bone models, handheld ultrasound probes and accessories for simulation training and clinical use, and offline training modules on demand and at minimal cost for traditional bone setters, nurses, clinical officers and up to 39,650 medical officers and surgeons across Nigeria who are not orthopedic specialists.^[26][27][28]

Acknowledgements[edit | edit source]

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References[edit | edit source]