Medical knowledge and surgical practice usually diffuse from a country's academic centers to the periphery. In the treatment of complex long bone fractures, SIGN in Kenya has reversed that process in a most significant way.

Through returning Kenyan orthopaedic surgeons trained at Mulago Hospital in Kampala, Uganda; American volunteers; and most importantly by word of mouth and direct exposure, Kenyan surgeons working at the provincial hospital level have seen that SIGN can answer many of their most pressing fracture problems and have been eager to learn the methods and use the system. It has changed their practice and given them a tool that is easy to use, dependable, and most importantly solves problems for which they previously had no solutions.

Kenya's public medical system consists of a hierarchical structure with dispensaries and clinics at the basic level, progressing to district hospitals in towns, eight provincial hospitals serving the more specialized medical and surgical needs of a large geographical area, and at the apex, Kenyetta hospital in Nairobi, the large teaching hospital.

The one constant of Kenya's public medical system is a lack of money. This translates to a paucity of drugs and supplies, underpaid staff, and a general apathy that pervades all levels of the system. As is common in centralized systems, prestigious hospitals in the capital receive a disproportionate share of the medical capital, leaving the provincial hospitals, which treat the vast bulk of the severe trauma, with few funds. ?

Of all the problems, it seems the least amount of thought is given to the proper treatment of trauma. Surgeons have no option but to treat complex fractures of the femur with inadequate traction, meaning a bag of rocks in a cloth bag, hung over the end of the bed and attached to the leg through a pin hammered into the top of the leg bone. This rarely unites the fracture, leaving the patient perhaps with a healed but crooked or shortened leg, or worse an unstable, unhealed bone on which they cannot walk.

Most of the long bone fractures are in young to middle aged males who work at marginal, unsafe occupations. Three months in traction resulting in a crippled or useless leg pushes them and their families into a poverty so deep there is little hope of relief.

Without a national universal social safety net, the first affected by these injuries are the children. Without money for mandatory school fees, children must abandon their education. Without money for adequate nutrition, they are susceptible to the myriad diseases that take their toll in chronic illness. Women become the sole support of the family, taking on poorly paid menial jobs, if they can find work at all. At all levels the family is disrupted by one femur fracture, which in the U.S. and Canada, is treated by a surgical implant with the patient discharged, walking within a few days.

The excitement of the orthopaedic surgeons using or being trained to use SIGN revolved around the many benefits of having a system of fracture treatment that works for them and the patients. For the first time any of them could remember, they could offer their patients a procedure, that being free of charge would not bankrupt the family, and when used properly would ensure that the patient could walk again and be out of bed within a few days of surgery.

Though all the surgeons emphasized the social value of SIGN when extolling its surgical value, I found in their words and expressions the professional pride of performing surgery they could be proud of, with beneficial results that were unequaled by any other system of fracture care available to them

With the surgeons in the provincial hospitals leading the way with advances in fracture fixation, I hope their advocacy will prove to those in the ministry of health that further investment in fracture care, is a wise move that will save money, lives, and families, making Kenya stronger and more productive.