Consensus definition and classification of neglected fractures and dislocations: protocol for an international modified Delphi study

Abstract

INTRODUCTION: Neglected fractures and dislocations are a common and clinically important problem in low- and middle-income countries, often attributed to limited access to timely orthopaedic care, financial barriers, referral delays and prior non-formal treatment. Despite their clinical significance, no standardised definition or classification exists. Reported time thresholds, defining criteria and classification approaches vary substantially across and even within anatomical regions, injury types and practice settings, limiting clinical communication, research comparability and burden estimation. This study aims to develop an expert consensus-based definition and classification system for neglected fractures and dislocations, focusing on identifying a common denominator applicable across various anatomical regions and injury types, using a modified Delphi methodology. METHODS AND ANALYSIS: A three-round, international, online modified Delphi study will be conducted involving purposively selected experts representing diverse geographical regions, subspecialties and practice settings, with approximately 200 experts invited to achieve a final panel of 20-30 participants. Questionnaire development was informed by a concurrent scoping review of the literature. Round 1 will explore the definitional elements and scope of the term as applied in orthopaedic practice, including the relative importance of temporal, biological, clinical and treatment-related factors that are often used to describe this entity, whether neglected fractures and dislocations are best conceptualised as a binary entity or a graded clinical spectrum, and whether defining criteria should vary across anatomical regions or different injury contexts. Round 2 will refine and present unresolved concepts and evaluate anatomic-specific operationalisation, including specific time thresholds and characteristic clinical and biological features. Round 3 will seek final consensus on the proposed definition and classification, including clarity, acceptability and perceived clinical usability. Consensus will be predefined as ≥70% agreement (7-9 on a 9-point Likert scale), with strong consensus defined as ≥80%. Free-text responses will undergo directed thematic content analysis. The study will be designed, conducted and reported in accordance with the Conducting and REporting of DElphi Studies (CREDES) checklist. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Addis Ababa University Institutional Review Board (reference: 007/26/Ortho). Findings will be disseminated through a peer-reviewed publication and presentations at scientific meetings. TRIAL REGISTRATION DETAILS: https://osf.io/jx4ew/overview?view_only=5bcabab130964c90ba0d2d1f17b8f247.