The use of traction for treating femoral shaft fractures in low- and middle-income countries: a systematic review

Abstract

Purpose

The use of traction for treatment of femoral shaft fractures remains common in low- and middle-income countries (LMICs). The objective of this study is to systematically review the literature on outcomes of traction as definitive treatment for adult femoral shaft fractures in LMICs.

Methods

Using the recommended PRISMA methods for systematic reviews, MEDLINE, EMBASE, LILACS, and AJOL were searched for relevant publications. Results were limited to studies occurring in LMICs as defined by the World Bank. Data on time spent in traction (TT), length of stay (LOS), time to partial weight bearing (PWB), complication incidences, and a total complication incidence were recorded.

Results

Of the 693 initial results, nine were eligible for analysis giving a total of 455 unique patients with a mean age of 32.9 years (range: 0 to 96). The average time spent in traction was 52.8 days (range: 19.8 to 122.5), the average length of stay was 55.4 days (range: 45 to 140), and the average time to partial weight bearing was 52.2 days (range: 42 to 60 days). There were a total of 91 malunions, 25 un-united fractures, 60 infections, 45 other complications, giving a total of 221 complications in 455 patients.

Conclusions

The use of traction in treating femoral shaft fractures is associated with a high incidence of complications and prolonged course of treatment. Although operative stabilization may be a better alternative, comparative studies are needed to assess whether this can be achieved in a safe and cost-effective manner for widespread application in LMICs.

Appendix A Search terminology and equations

MEDLINE (4/23/2014)

“Traction AND (femoral fractures[Mesh] OR femur[tiab] OR femoral[tiab] OR leg bone*[tiab] OR long bone*[tiab]) AND (Afghanistan[Mesh] OR Bangladesh[Mesh] OR Benin[Mesh] OR Burkina Faso[Mesh] OR Burundi[Mesh] OR Cambodia[Mesh] OR Central African Republic[Mesh] OR Chad[Mesh] OR Comoros[Mesh] OR Democratic Republic of the Congo[Mesh] OR Eritrea[Mesh] OR Ethiopia[Mesh] OR Gambia[Mesh] OR Guinea[Mesh] OR Guinea-Bissau[Mesh] OR Haiti[Mesh] OR Kenya[Mesh] OR Democratic People's Republic of Korea[Mesh] OR Kyrgyzstan[Mesh] OR Liberia[Mesh] OR Madagascar[Mesh] OR Malawi[Mesh] OR Mali[Mesh] OR Mozambique[Mesh] OR Myanmar[Mesh] OR Nepal[Mesh] OR Niger[Mesh] OR Rwanda[Mesh] OR Sierra Leone[Mesh] OR Somalia[Mesh] OR Sudan[Mesh] OR Tajikistan[Mesh] OR Tanzania[Mesh] OR Togo[Mesh] OR Uganda[Mesh] OR Zimbabwe[Mesh] OR Armenia[Mesh] OR Bhutan[Mesh] OR Bolivia[Mesh] OR Cameroon[Mesh] OR Cape Verde[Mesh] OR Congo[Mesh] OR Cote d'Ivoire[Mesh] OR Djibouti[Mesh] OR Egypt[Mesh] OR El Salvador[Mesh] OR "Georgia (Republic)"[Mesh] OR Ghana[Mesh] OR Guatemala[Mesh] OR Guyana[Mesh] OR Honduras[Mesh] OR Indonesia[Mesh] OR India[Mesh] OR Kosovo[Mesh] OR Laos[Mesh] OR Lesotho[Mesh] OR Mauritania[Mesh] OR Moldova[Mesh] OR Mongolia[Mesh] OR Morocco[Mesh] OR Nicaragua[Mesh] OR Nigeria[Mesh] OR Pakistan[Mesh] OR Papua New Guinea[Mesh] OR Paraguay[Mesh] OR Philippines[Mesh] OR Samoa[Mesh:noexp] OR Independent State of Samoa[Mesh] OR Senegal[Mesh] OR Sri Lanka[Mesh] OR Sudan[Mesh] OR Swaziland[Mesh] OR Syria[Mesh] OR East Timor[Mesh] OR Ukraine[Mesh] OR Uzbekistan[Mesh] OR Vanuatu[Mesh] OR Vietnam[Mesh] OR Yemen[Mesh] OR Zambia[Mesh] OR Afghani*[tiab] OR Bangladesh*[tiab] OR Benin[tiab] OR "Burkina Faso"[tiab] OR Burundi*[tiab] OR Cambodia*[tiab] OR "Central African Republic"[tiab] OR Chad[tiab] OR Comoros[tiab] OR Congo*[tiab] OR Zaire[tiab] OR Eritrea*[tiab] OR Ethiopia*[tiab] OR Gambia*[tiab] OR Guinea*[tiab] OR "Guinea-Bissau"[tiab] OR Haiti*[tiab] OR Kenya*[tiab] OR "Democratic People's Republic of Korea"[tiab] OR "North Korea"[tiab] OR North Korean*[tiab] OR Kyrgyz*[tiab] OR Liberia*[tiab] OR Madagascar[tiab] OR Malawi[tiab] OR Malawian*[tiab] OR Mali[tiab] OR Mozambique[tiab] OR Myanmar[tiab] OR Burma[tiab] OR Burmese[tiab] OR Nepal[tiab] OR Nepalese[tiab] OR Niger[tiab] OR Rwanda*[tiab] OR "Sierra Leone"[tiab] OR Somalia[tiab] OR Somali[tiab] OR Somalis[tiab] OR "South Sudan"[tiab] OR Tajikistan*[tiab] OR Tadjikistan*[tiab] OR Tanzania*[tiab] OR Zanzibar*[tiab] OR Tanganyika[tiab] OR Togo[tiab] OR Togolese[tiab] OR Uganda*[tiab] OR Zimbabw*[tiab] OR Rhodesia*[tiab] OR Armenia*[tiab] OR Bhutan*[tiab] OR Bolivia*[tiab] OR Cameroon*[tiab] OR "Cape Verde"[tiab] OR "Cote d'Ivoire"[tiab] OR "Ivory Coast"[tiab] OR Djibouti*[tiab] OR Egypt*[tiab] OR El Salvador*[tiab] OR "Georgia Republic"[tiab] OR "Republic of Georgia"[tiab] OR Ghana*[tiab] OR Guatemal*[tiab] OR Guyana[tiab] OR Guyanese[tiab] OR "British Guiana"[tiab] OR Hondur*[tiab] OR India[tiab] OR "Asian Indian"[tiab] OR "Asian Indians"[tiab] OR Indonesia*[tiab] OR Kiribati[tiab] OR Kosovo[tiab] OR Kosovan*[tiab] OR Kosovar*[tiab] OR Laos[tiab] OR "Lao PDR"[tiab] OR "LAO People's Democratic Republic"[tiab] OR Lao people*[tiab] OR Laotian*[tiab] OR Lesotho*[tiab] OR Mauritania*[tiab] OR (Micronesia*[tiab] AND "Federated States"[tiab]) OR Moldova*[tiab] OR Mongolia*[tiab] OR Morocc*[tiab] OR Nicaragua*[tiab] OR Nigeria*[tiab] OR Pakistan*[tiab] OR "Papua New Guinea"[tiab] OR Paraguay[tiab] OR Paraguayan*[tiab] OR Philippines[tiab] OR Filipino*[tiab] OR Filipina*[tiab] OR Samoa*[tiab] OR "Sao Tome"[tiab] OR Senegal[tiab] OR Senegalese[tiab] OR Solomon Island*[tiab] OR "Sri Lanka"[tiab] OR Sri Lankan*[tiab] OR Ceylon[tiab] OR Sudan*[tiab] OR Swaziland[tiab] OR Syria*[tiab] OR "Timor-Leste"[tiab] OR "East Timor"[tiab] OR Ukrain*[tiab] OR Uzbekistan*[tiab] OR Vanuatu*[tiab] OR Vietnam*[tiab] OR "West Bank"[tiab] OR Gaza[tiab] OR Palestin*[tiab] OR Yemen*[tiab] OR Zambia*[tiab] OR Afghanistan[ad] OR Bangladesh[ad] OR Benin[ad] OR “Burkina Faso”[ad] OR Burundi[ad] OR Cambodia[ad] OR “Central African Republic”[ad] OR Chad[ad] OR Comoros[ad] OR Congo[ad] OR Zaire[ad] OR Eritrea[ad] OR Ethiopia[ad] OR Gambia[ad] OR Guinea[ad] OR “Guinea-Bissau”[ad] OR Haiti[ad] OR Kenya[ad] OR “Democratic People's Republic of Korea”[ad] OR “North Korea”[ad] OR Kyrgyz* [ad] OR Liberia[ad] OR Madagascar[ad] OR Malawi[ad] OR Mali[ad] OR Mozambique[ad] OR Myanmar[ad] OR Burma[ad] OR Nepal[ad] OR Niger[ad] OR Rwanda[ad] OR “Sierra Leone”[ad] OR Somalia[ad] OR “South Sudan”[ad] OR Tajikistan[ad] OR Tadjikistan OR Tanzania[ad] OR Zanzibar[ad] OR Tanganyika[ad] OR Togo[ad] OR Uganda[ad] OR Zimbabwe[ad] OR Rhodesia[ad] OR Armenia[ad] OR Bhutan[ad] OR Bolivia[ad] OR Cameroon[ad] OR “Cape Verde”[ad] OR “Cote d'Ivoire”[ad] OR “Ivory Coast”[ad] OR Djibouti[ad] OR Egypt[ad] OR “El Salvador”[ad] OR “Georgia Republic”[ad] OR “Republic of Georgia”[ad] OR Ghana[ad] OR Guatemala[ad] OR Guyana[ad] OR Honduras[ad] OR India[ad] OR Indonesia[ad] OR Kiribati[ad] OR Kosovo[ad] OR Laos[ad] OR “Lao PDR” OR LAO People*[ad] OR Lesotho[ad] OR Mauritania[ad] OR “Federated States of Micronesia”[ad] OR Moldova[ad] OR Mongolia[ad] OR Morocco[ad] OR Nicaragua[ad] OR Nigeria[ad] OR Pakistan[ad] OR “Papua New Guinea”[ad] OR Paraguay[ad] OR Philippines[ad] OR Samoa[ad] OR “Sao Tome”[ad] OR Senegal[ad] OR “Solomon Islands”[ad] OR “Sri Lanka”[ad] OR Ceylon[ad] OR Sudan[ad] OR Swaziland[ad] OR Syria[ad] OR “Syrian Arab Republic”[ad] OR “Timor-Leste”[ad] OR “East Timor”[ad] OR Ukraine[ad] OR Uzbekistan[ad] OR Vanuatu[ad] OR Vietnam[ad] OR “West Bank”[ad] OR Gaza[ad] OR Palestine[ad] OR Yemen[ad] OR Zambia[ad] OR Angola[Mesh] OR Albania[Mesh] OR Algeria[Mesh] OR Argentina[Mesh] OR Azerbaijan[Mesh] OR Belarus[Mesh] OR Belize[Mesh] OR “Bosnia and Herzegovina”[Mesh] OR Botswana[Mesh] OR Brazil[Mesh] OR Bulgaria[Mesh] OR China[Mesh] OR Colombia[Mesh] OR “Costa Rica”[Mesh] OR Cuba[Mesh] OR Dominica[Mesh] OR “Dominican Republic”[Mesh] OR Ecuador[Mesh] OR Fiji[Mesh] OR Gabon[Mesh] OR Grenada[Mesh] OR Hungary[Mesh] OR Iran[Mesh] OR Iraq[Mesh] OR Jamaica[Mesh] OR Jordan[Mesh] OR Kazakhstan[Mesh] OR Lebanon[Mesh] OR Libya[Mesh] OR Macedonia[Mesh] OR Malaysia[Mesh] OR Maldives[Mesh] OR “Marshall Islands”[Mesh] OR Mauritius[Mesh] OR Mexico[Mesh] OR Montenegro[Mesh] OR Namibia[Mesh] OR Palau[Mesh] OR Panama[Mesh] OR Peru[Mesh] OR Romania[Mesh] OR Serbia[Mesh] OR Seychelles[Mesh] OR South Africa[Mesh] OR St. Lucia[Mesh] OR “St. Vincent and the Grenadines”[Mesh] OR Suriname[Mesh] OR Thailand[Mesh] OR Tonga[Mesh] OR Tunisia[Mesh] OR Turkey[Mesh] OR Turkmenistan[Mesh] OR Tuvalu[Mesh] OR Venezuela OR Angola*[Tiab] OR Albania*[Tiab] OR Algeria*[Tiab] OR Argentin*[Tiab] OR Azerbai*[Tiab] OR Belarus*[Tiab] OR Beli*[Tiab] OR “Bosnia and Herzegovina”[Tiab] OR Botswan*[Tiab] OR Brazil*[Tiab] OR Bulgaria*[Tiab] OR China[Tiab] OR Chinese[Tiab] OR Colombia*[Tiab] OR “Costa Rica”[Tiab] OR “Costa Rican”[Tiab] OR Cuba*[Tiab] OR Dominica*[Tiab] OR “Dominican Republic”[Tiab] OR Ecuador*[Tiab] OR Fiji*[Tiab] OR Gabon*[Tiab] OR Grenada*[Tiab] OR Hungary[Tiab] OR Hungarian[Tiab] OR Iran*[Tiab] OR Iraq*[Tiab] OR Jamaica*[Tiab] OR Jordan*[Tiab] OR Kazakhstan*[Tiab] OR Lebanon[Tiab] OR Lebanese[Tiab] OR Libya*[Tiab] OR Macedonia*[Tiab] OR Malaysia*[Tiab] OR Maldives[Tiab] OR Maldivian[Tiab] OR “Marshall Islands”[Tiab] OR Mauritius[Tiab] OR Mexico[Tiab] OR Mexican[Tiab] OR Montenegro[Tiab] OR Namibia*[Tiab] OR Palau*[Tiab] OR Panama*[Tiab] OR Peru*[Tiab] OR Romania*[Tiab] OR Serbia*[Tiab] OR Seychelles[Tiab] OR South Africa*[Tiab] OR St. Lucia*[Tiab] OR “St. Vincent and the Grenadines”[Tiab] OR Surinam*[Tiab] OR Thailand [Tiab] OR Thai[Tiab] OR Tonga*[Tiab] OR Tunisia*[Tiab] OR Turkey[Tiab] OR Turkish[Tiab] OR Turkmenistan*[Tiab] OR Tuvalu*[Tiab] OR Venezuela* OR Angola[Ad] OR Albania[Ad] OR Algeria[Ad] OR Argentina[Ad] OR Azerbaijan[Ad] OR Belarus[Ad] OR Belize[Ad] OR “Bosnia and Herzegovina”[Ad] OR Botswana[Ad] OR Brazil[Ad] OR Bulgaria[Ad] OR China[Ad] OR Colombia[Ad] OR “Costa Rica”[Ad] OR Cuba[Ad] OR Dominica[Ad] OR “Dominican Republic”[Ad] OR Ecuador[Ad] OR Fiji[Ad] OR Gabon[Ad] OR Grenada[Ad] OR Hungary[Ad] OR Iran[Ad] OR Iraq[Ad] OR Jamaica[Ad] OR Jordan[Ad] OR Kazakhstan[Ad] OR Lebanon[Ad] OR Libya[Ad] OR Macedonia[Ad] OR Malaysia[Ad] OR Maldives[Ad] OR “Marshall Islands”[Ad] OR Mauritius[Ad] OR Mexico[Ad] OR Montenegro[Ad] OR Namibia[Ad] OR Palau[Ad] OR Panama[Ad] OR Peru[Ad] OR Romania[Ad] OR Serbia[Ad] OR Seychelles[Ad] OR South Africa[Ad] OR St. Lucia[Ad] OR “St. Vincent and the Grenadines”[Ad] OR Suriname[Ad] OR Thailand[Ad] OR Tonga[Ad] OR Tunisia[Ad] OR Turkey[Ad] OR Turkmenistan[Ad] OR Tuvalu[Ad] OR Venezuela OR developing countries[Mesh] OR "developing country"[tiab] OR "developing countries"[tiab] OR LMIC[tiab] OR LMICs[tiab] OR "low income countries"[tiab] OR "low income country"[tiab] OR "low and middle income countries"[tiab] OR "low and middle income country"[tiab] OR "lower middle income countries"[tiab] OR "lower middle income country"[tiab] OR "developing nation"[tiab] OR "developing nations"[tiab] OR "developing world"[tiab] OR "developing economy"[tiab] OR "developing economies"[tiab] OR "transitional country"[tiab] OR "transitional countries"[tiab] OR "global burden"[tiab] OR "global health"[tiab] OR global orthop*[tiab] OR "global outreach"[tiab] OR "global public health"[tiab] OR (global[ti] AND watch[ti]) OR global[ti] OR "international health"[tiab] OR "international public health"[tiab] OR world health[majr] OR international cooperation[majr] OR "resource poor"[tiab] OR austere environment*[tiab] OR “limited resource”[tiab] OR “limited resources”[tiab] OR "third world"[tiab] OR Africa[Mesh] OR Africa*[tiab] OR sahara*[tiab] OR subsahara*[tiab] OR Asia[Mesh] OR asia*[tiab] OR Central America[Mesh] OR central America*[tiab] OR Europe, Eastern[Mesh] OR eastern Europe*[tiab] OR South America[Mesh] OR South America*[tiab] OR Caribbean Region[Mesh] OR Caribbean[tiab] OR Middle East[Mesh:noexp] OR USSR[Mesh] OR ussr[tiab] OR ussr[ad] OR u.s.s.r.[tiab] OR u.s.s.r.[ad] OR “Union of Soviet Socialist Republics”[tiab] OR “Union of Soviet Socialist Republics”[ad] OR “Soviet Union”[tiab] OR “Soviet Union”[ad] OR Soviet*[tiab] OR Russia*[tiab] OR Russia*[ad] OR Yugoslavia[Mesh] OR Yugoslav*[tiab] OR Yugoslav*[ad]) NOT (animals[Mesh] NOT humans[Mesh]”

EMBASE (4/25/2014)

“traction AND ('femur fracture'/exp OR femur:ab,ti OR femoral:ab,ti OR 'leg bone':ab,ti OR 'leg bones':ab,ti OR 'long bone':ab,ti OR 'long bones':ab,ti OR 'leg fracture'/mj) AND ('afghanistan'/de OR 'bangladesh'/de OR 'benin'/de OR 'burkina faso'/de OR 'burundi'/de OR 'cambodia'/de OR 'central african republic'/de OR 'chad'/de OR 'comoros'/de OR 'democratic republic congo'/de OR 'eritrea'/de OR 'ethiopia'/de OR 'gambia'/de OR 'guinea'/de OR 'guinea-bissau'/de OR 'haiti'/de OR 'kenya'/de OR 'north korea'/de OR 'kyrgyzstan'/de OR 'liberia'/de OR 'madagascar'/de OR 'malawi'/de OR 'mali'/de OR 'mozambique'/de OR 'myanmar'/de OR 'nepal'/de OR 'niger'/de OR 'rwanda'/de OR 'sierra leone'/de OR 'somalia'/de OR 'tajikistan'/de OR 'tanzania'/de OR 'togo'/de OR 'uganda'/de OR 'zimbabwe'/de OR 'armenia'/de OR 'bhutan'/de OR 'bolivia'/de OR 'cameroon'/de OR 'cape verde'/de OR 'congo'/de OR 'cote d`ivoire'/exp OR 'djibouti'/de OR 'egypt'/de OR 'el salvador'/de OR 'georgia (republic)'/de OR 'ghana'/de OR 'guatemala'/de OR 'guyana'/de OR 'honduras'/de OR 'indonesia'/de OR 'india'/de OR 'kosovo'/de OR 'laos'/de OR 'lesotho'/de OR 'mauritania'/de OR 'federated states of micronesia'/de OR 'moldova'/de OR 'mongolia'/de OR 'morocco'/de OR 'nicaragua'/de OR 'nigeria'/de OR 'pakistan'/de OR 'papua new guinea'/de OR 'paraguay'/de OR 'philippines'/de OR 'samoa'/de OR 'sao tome and principe'/de OR 'senegal'/de OR 'solomon islands'/de OR 'sri lanka'/de OR 'sudan'/de OR 'swaziland'/de OR 'syrian arab republic'/de OR 'timor-leste'/de OR 'ukraine'/de OR 'uzbekistan'/de OR 'vanuatu'/de OR 'vietnam'/de OR 'palestine'/de OR 'yemen'/de OR 'zambia'/de OR afghani*:ab,ti OR bangladesh*:ab,ti OR benin:ab,ti OR 'burkina faso':ab,ti OR burundi*:ab,ti OR cambodia*:ab,ti OR 'central african republic':ab,ti OR chad:ab,ti OR comoros:ab,ti OR congo:ab,ti OR congolese:ab,ti OR zaire:ab,ti OR eritrea*:ab,ti OR ethiopia*:ab,ti OR gambia*:ab,ti OR guinea*:ab,ti OR 'guinea-bissau':ab,ti OR haiti*:ab,ti OR kenya*:ab,ti OR 'north korea':ab,ti OR 'north korean':ab,ti OR 'north koreans':ab,ti OR kyrgyz*:ab,ti OR liberia*:ab,ti OR madagascar:ab,ti OR malawi:ab,ti OR mali:ab,ti OR mozambique:ab,ti OR myanmar:ab,ti OR burma:ab,ti OR burmese:ab,ti OR nepal:ab,ti OR nepalese:ab,ti OR niger:ab,ti OR rwanda*:ab,ti OR 'sierra leone':ab,ti OR somalia:ab,ti OR somali:ab,ti OR somalis:ab,ti OR 'south sudan':ab,ti OR tajikistan*:ab,ti OR tadjikistan*:ab,ti OR tanzania*:ab,ti OR zanzibar*:ab,ti OR tanganyika:ab,ti OR togo:ab,ti OR togolese:ab,ti OR uganda*:ab,ti OR zimbabw*:ab,ti OR rhodesia*:ab,ti OR armenia*:ab,ti OR bhutan*:ab,ti OR bolivia*:ab,ti OR cameroon*:ab,ti OR 'cape verde':ab,ti OR ivoire:ab,ti OR 'ivory coast':ab,ti OR djibouti*:ab,ti OR egypt*:ab,ti OR 'el salvador':ab,ti OR 'el salvadoran':ab,ti OR 'el salvadorans':ab,ti OR 'georgia republic':ab,ti OR 'republic of georgia':ab,ti OR ghana*:ab,ti OR guatemal*:ab,ti OR guyana:ab,ti OR guyanese:ab,ti OR 'british guiana':ab,ti OR hondur*:ab,ti OR india:ab,ti OR 'asian indian':ab,ti OR 'asian indians':ab,ti OR indonesia*:ab,ti OR kiribati:ab,ti OR kosovo:ab,ti OR laos:ab,ti OR 'lao pdr':ab,ti OR laotian*:ab,ti OR 'lao people':ab,ti OR 'lao peoples':ab,ti OR lesotho*:ab,ti OR mauritania*:ab,ti OR (micronesia:ab,ti AND 'federated states') OR moldova:ab,ti OR mongolia*:ab,ti OR morocc*:ab,ti OR nicaragua*:ab,ti OR nigeria*:ab,ti OR pakistan*:ab,ti OR 'papua new guinea':ab,ti OR paraguay:ab,ti OR philippines:ab,ti OR filipino*:ab,ti OR filipina*:ab,ti OR samoa*:ab,ti OR 'sao tome':ab,ti OR senegal:ab,ti OR senegalese:ab,ti OR 'solomon island':ab,ti OR 'solomon islands':ab,ti OR 'sri lanka':ab,ti OR 'sri lankan':ab,ti OR 'sri lankans':ab,ti OR ceylon:ab,ti OR sudan*:ab,ti OR swaziland:ab,ti OR syria*:ab,ti OR 'timor-leste':ab,ti OR 'east timor':ab,ti OR ukrain*:ab,ti OR uzbekistan*:ab,ti OR vanuatu*:ab,ti OR vietnam*:ab,ti OR 'west bank':ab,ti OR gaza:ab,ti OR palestin*:ab,ti OR yemen*:ab,ti OR zambia*:ab,ti OR afghanistan:ad OR bangladesh:ad OR benin:ad OR 'burkina faso':ad OR burundi:ad OR cambodia:ad OR 'central african republic':ad OR chad:ad OR comoros:ad OR congo:ad OR zaire:ad OR eritrea:ad OR ethiopia:ad OR gambia:ad OR guinea:ad OR 'guinea-bissau':ad OR haiti:ad OR kenya:ad OR (democratic:ad AND 'republic of korea':ad) OR 'north korea':ad OR kyrgyz*:ad OR liberia:ad OR madagascar:ad OR malawi:ad OR mali:ad OR mozambique:ad OR myanmar:ad OR burma:ad OR nepal:ad OR niger:ad OR rwanda:ad OR 'sierra leone':ad OR somalia:ad OR 'south sudan':ad OR tajikistan:ad OR tadjikistan OR tanzania:ad OR zanzibar:ad OR tanganyika:ad OR togo:ad OR uganda:ad OR zimbabwe:ad OR rhodesia:ad OR armenia:ad OR bhutan:ad OR bolivia:ad OR cameroon:ad OR 'cape verde':ad OR ivoire:ad OR 'ivory coast':ad OR djibouti:ad OR egypt:ad OR 'el salvador':ad OR 'georgia republic':ad OR 'republic of georgia':ad OR ghana:ad OR guatemala:ad OR guyana:ad OR honduras:ad OR india:ad OR indonesia:ad OR kiribati:ad OR kosovo:ad OR laos:ad OR 'lao pdr':ad OR 'lao people':ad OR lesotho:ad OR mauritania:ad OR 'federated states of micronesia':ad OR moldova:ad OR mongolia:ad OR morocco:ad OR nicaragua:ad OR nigeria:ad OR pakistan:ad OR 'papua new guinea':ad OR paraguay:ad OR philippines:ad OR samoa:ad OR 'sao tome':ad OR senegal:ad OR 'solomon islands':ad OR 'sri lanka':ad OR ceylon:ad OR sudan:ad OR swaziland:ad OR syria:ad OR 'syrian arab republic':ad OR 'timor-leste':ad OR 'east timor':ad OR ukraine:ad OR uzbekistan:ad OR vanuatu:ad OR vietnam:ad OR 'west bank':ad OR gaza:ad OR palestine:ad OR yemen:ad OR zambia:ad OR 'developing country'/de OR 'developing country':ab,ti OR 'developing countries':ab,ti OR lmic:ab,ti OR lmics:ab,ti OR 'low income countries':ab,ti OR 'low income country':ab,ti OR 'low and middle income countries':ab,ti OR 'low and middle income country':ab,ti OR 'lower middle income countries':ab,ti OR 'lower middle income country':ab,ti OR 'developing nation':ab,ti OR 'developing nations':ab,ti OR 'developing world':ab,ti OR 'developing economy':ab,ti OR 'developing economies':ab,ti OR 'transitional country':ab,ti OR 'transitional countries':ab,ti OR 'global burden':ab,ti OR 'global health':ab,ti OR 'global orthopedic':ab,ti OR 'global orthopedics':ab,ti OR 'global orthopaedic':ab,ti OR 'global orthopaedics':ab,ti OR 'global orthopedist':ab,ti OR 'global orthopedists':ab,ti OR 'global orthopaedist':ab,ti OR 'global orthopaedists':ab,ti OR 'global outreach':ab,ti OR 'global public health':ab,ti OR 'global watch':ab,ti OR global:ti OR 'international health':ab,ti OR 'international public health':ab,ti OR 'international cooperation'/mj OR 'resource poor':ab,ti OR 'austere environment':ab,ti OR 'limited resource':ab,ti OR 'limited resources':ab,ti OR 'third world':ab,ti OR 'africa'/exp OR africa*:ab,ti OR sahara*:ab,ti OR subsahara*:ab,ti OR 'asia'/exp OR asia*:ab,ti OR 'south and central america'/exp OR 'central america':ab,ti OR 'central americas':ab,ti OR 'central american':ab,ti OR 'central americans':ab,ti OR 'south america':ab,ti OR 'south americas':ab,ti OR 'south american':ab,ti OR 'south americans':ab,ti OR 'eastern europe'/exp OR 'eastern europe':ab,ti OR 'eastern european':ab,ti OR 'eastern europeans':ab,ti OR 'caribbean islands'/exp OR caribbean:ab,ti OR 'middle east'/de OR 'ussr'/exp OR ussr:ab,ti OR ussr:ad OR 'u s s r':ab,ti OR 'u s s r':ad OR 'union of soviet socialist republics':ab,ti OR 'union of soviet socialist republics':ad OR 'soviet union':ab,ti OR 'soviet union':ad OR soviet*:ab,ti OR russia*:ab,ti OR russia*:ad OR 'yugoslavia (pre-1992)'/exp OR yugoslav*:ab,ti OR yugoslav*:ad) NOT ([animals]/lim NOT ([humans]/lim OR 'patient'/exp))”

LILACS (4/3/2014)

1. “femur” AND “traction;” 2. “femoral” AND “traction.”

AJOL (4/3/2014)

“femur” OR “femoral” AND “traction.”

Eq. 1

“${\displaystyle \sum_{\mathrm{i}=1}^{\mathrm{k}}}{n}_i{m}_i \div {\displaystyle \sum_{i=1}^{\mathrm{k}}}{n}_i$” where “n” is the number of patients in a study, “m” is the reported mean for the given variable, and “k” is the number of studies used.

Eq. 2

“$\left({\displaystyle \sum_{\mathrm{i}=1}^{\mathrm{k}}}{n}_i{\widehat{p}}_i \div {\displaystyle \sum_{i=1}^k}{\widehat{p}}_i\right)\div$ ($\left[{\displaystyle \sum_{\mathrm{i}=1}^{\mathrm{k}}}{n}_i\right]\div k$)” where “$\widehat{p}$” is the proportion of patients suffering specified complication events.