Fractures in the System: Local Voices and Global Strategies for Orthopaedic Reform in Nigeria.

Background: Musculoskeletal trauma accounts for a major share of global disability, yet access to orthopaedic care in low- and middle-income countries remains severely limited. This narrative review explores the systemic disparities in Nigeria, the most populous country in Africa, based on semistructured interviews with orthopaedic surgeons, field observations from a multinational clinical collaboration, and analysis of published literature and policy data. Methods: Semistructured interviews were conducted with attending and resident orthopaedic surgeons at a national referral hospital in Lagos. Observational data were gathered during a multi-institutional orthopaedic site visit. Themes were triangulated with the literature from peer-reviewed journals, health policy documents, and global health reports to construct a multilevel review of structural, sociocultural, and economic barriers to musculoskeletal care. Results: We identified 3 major drivers of orthopaedic inequity. First, economic constraints: more than 90% of patients pay out-of-pocket and with implant and surgery costs often exceed annual household income, care is often delayed or forgone. Second, sociocultural barriers: Patients often first seek treatment from traditional bone setters whose unregulated practices result in complications such as malunions, infections, and delayed presentation. Third, workforce-related limitations: Nigeria has fewer than 500 orthopaedic surgeons for more than 200,000,000 people. Many providers report burnout, limited access to advanced training, and a growing desire to emigrate because of low salaries and resource scarcity. Conclusions: Proposed reforms include national insurance expansion, rural trauma center development, regulation of informal care networks, and global-academic partnerships. Orthopaedic equity in Nigeria will require both local leadership and sustained international investment that prioritizes capacity building. This review highlights a scalable collaboration model that may inform future global orthopaedic engagement strategies. Clinical Relevance: This study highlights critical barriers to orthopaedic care delivery in Nigeria, including financial hardship, workforce shortages, and infrastructure deficits, which contribute to delayed treatment and poor surgical outcomes. By identifying locally grounded, cost-effective strategies-such as integrating traditional providers, expanding telemedicine, and building global partnerships-this work offers a scalable framework for improving musculoskeletal care access in low-resource settings worldwide.