Traumatic brain injury (TBI) is a major cause of death and disability among the trauma patient population worldwide [14]. While exact statistics are lacking, TBI is a particular problem in developing countries [15]. In certain trauma populations in the developing world, the incidence of TBI has been reported to be as high as 74 % [16]; according to the WHO, head injury is one of the major causes of trauma-related disability and death worldwide [1].

While guidelines [17, 18] established for the management of severe TBI have shown to improve survival and functional outcome after severe head injury in high-income countries [19], these protocols require expensive resources, including CT. For example, post-traumatic extra-axial hemorrhage, diagnosed by CT, can require neurosurgical decompression for decreased morbidity and mortality. Even when CT scanners are present in low-income countries, many factors often render them unusable, including prohibitive maintenance costs and consequent long periods of breakdown [20]. If CT scanning is available in the setting of head trauma, the WHO has recommended that basic quality improvement programs should assure that all patients warranting CT scan of the head (generally Glasgow coma scale of 8 or less) can be imaged within 2 h of presentation [1]. It is important to consider that while current treatment strategies for TBI have been validated in the western medical literature [21], the effectiveness is unknown in the setting of inadequate infrastructure, absence of advanced medical imaging, lack of emergency medical services, and/or limited ICU availability [3].

Like TBI, traumatic spinal cord injury (TSCI) is an increasing health care challenge in the developing world. While difficult to gather exact statistics, the average age of patients with TSCI in the developing world has been reported to be below 30 years old [22], a devastating statistic given the high morbidity associated with TSCI. There is generally a high male to female ratio in TSCI, with reported ratios as high as 7.5:1 having been reported in the literature [23]. While falls are reported to be the most common primary cause of traumatic spinal cord injury in developing countries, with incidence ranging from 23 [24] to 37 % [25], many developing countries now report traffic accidents as the most common cause of TSCI [26].

The management of TSCI is challenging, even with a full complement of diagnostic and therapeutic resources available. While several studies have assessed short- and long-term survival rates after TSCI in developed countries, very few long-term outcome studies exist in developing countries. One study from Zimbabwe reported a 1-year survival rate of approximately 51 % [27], a significant improvement from earlier unpublished data from the same group. A separate study from Sierra Leone reported an in-hospital mortality rate of 29.2 % in the setting of TSCI [28], which was approximately three times higher than a similar series from Brazil [29], a much more affluent developing country. Recognition of the presence of risk of spinal injury is essential at all levels of the health care system.

While clinical evaluation is the first critical step in the evaluation of suspected spinal cord injury, radiographs are a very helpful adjunct and are considered the minimum requirement for imaging evaluation. The incidence of TSCI, like TBI, is likely to increase as the prevalence of motor vehicles continues to increase in the developing world. Many authors have advocated for a more comprehensive spinal injury response system in developing countries, including environment modification, vocational rehabilitation, and caregiver education [28].

In addition to TBI and TSCI, post-traumatic abdominal injury (both blunt and penetrating) is an increasing cause of morbidity and mortality worldwide. As with TBI and TSCI, while physical examination and clinical evaluation of trauma patients are the first steps in evaluation, these methods are significantly augmented in the acute setting with ultrasound or CT capabilities. Ultrasonography is the primary method of screening patients with blunt abdominal trauma worldwide [30, 31]. Focused assessment with sonography for trauma (FAST) is a rapid bedside ultrasound examination which can be used to screen for the presence of free fluid in the abdomen or pelvis [32], the presence of which suggests traumatic gastrointestinal tract injury and has important clinical and management implications in the post-traumatic setting. According to previous reports, the morbidity of gastrointestinal tract injury is mostly related to delays in diagnosis [33].

Because of the much wider availability of ultrasound in the developing world, FAST is a very important diagnostic application in the setting of trauma. A Cochrane systematic review found that the sensitivity of FAST for detecting hemoperitoneum in trauma patients was 85–95 % [34]; the average specificity of FAST for intra-abdominal blunt trauma has been reported as 90–99 % [34–36], with one study investigating FAST in a developing world setting reporting a specificity of 100 %, regardless of mechanism of injury [37]. FAST scanning expedites the appropriate triage of trauma patients, decreasing time to definitive care and reducing demands for CT scanning, which is particularly important in low-resource areas [37]. Repeated scanning has been shown to increase the sensitivity of FAST to above 90 % for detection of the presence of free intraperitoneal fluid [38, 39]. FAST is often considered less sensitive than other methods of determining the extent of post-traumatic intra-abdominal injury such as diagnostic peritoneal lavage (DPL) or CT. However, a direct comparison of FAST and DPL showed FAST scans to be a good alternative, with a similar specificity and a much lower complication rate [40]. While CT remains the gold standard for assessment of intra-abdominal traumatic injury, FAST is an acceptable alternative in resource-poor facilities, where CT is often unavailable [41, 42]. Despite the high negative predictive value of FAST in blunt trauma, reported as 91.6 % in one study [37], it is important to remember that the absence of free fluid on FAST scanning does not exclude intra-abdominal injury, with one study revealing the presence of visceral injury on CT in 34 % of patients with no evidence of hemoperitoneum on FAST evaluation [43].

As described elsewhere in the text, ultrasound is an excellent but heavily operator-dependent modality, and optimal use of ultrasound for assessment of trauma necessitates an effectively trained team of sonographers and/or other clinically based professionals, including physicians and nurses. Ultimately any strategy seeking to incorporate clinical ultrasound in LMIC for trauma evaluation will require an effective clinical education component for effective implementation beyond simply equipment procurement related efforts.

In addition to TBI, TSCI, and traumatic abdominal injury, traumatic injury of the extremities is a significant worldwide cause of morbidity. Socioeconomic change within developing countries, as described at the beginning of this chapter, including an increased dependence on motor vehicles, has resulted in a significant increase both in the number and in the complexity of injuries of the extremities [44, 45]. Resources are often in short supply to address such injuries. This has led, as one author described, to the dilemma in developing countries of attempting to manage what can be termed “first-world injuries using third-world facilities” [4]. Untreated fractures, many of which are the result of road traffic accidents as previously described, are a major burden of disease.

Musculoskeletal disabilities can be greatly reduced if promptly recognized and corrected [1]. X-ray facilities are generally designated as essential by the WHO for the diagnosis, treatment, and successful management of skeletal injuries. In addition, portable X-ray capability greatly facilitates the diagnosis of skeletal injury and the management of patients in traction and during operative procedures. C-arm fluoroscopy is also a very important component of many orthopedic interventions in the setting of trauma, as it reduces operative time, can decrease radiation exposure, and allows for closed, rather than open, procedures [46, 47].

It is estimated that two thirds of the world has no access to orthopedic care as the majority of the world’s orthopedic surgeons are found in high-income countries. In countries with poor access to resources, nonoperative treatment is often offered for fractures, despite the fact that operative repair would result in a better functional outcome. The reasons for this include the unavailability of implants, deficiency of equipment and imaging capability, and lack of surgical training. While the majority of fractures will heal whether or not formal treatment is undertaken, the problem is that healing may not occur in the desired position or alignment, thus compromising function [4]. In general, extremity trauma continues to constitute a major trauma-related problem in the developing world and proves to be a multifactorial problem.

Organized trauma teams have proven to be a vital adjunct to medical imaging in the successful treatment of trauma patients in the developed world. One study reported that in the presence of an organized trauma team, resuscitation time was reduced by 54 % [48]. This was interpreted to be a result of task allocation and the adoption of simultaneous rather than sequential resuscitation. The involvement of an experienced senior trauma team leader, who was not actively involved in the physical aspects of the resuscitation, was found to help shorten resuscitation times [49]. Compared to resuscitations without a designated team leader, resuscitations that had a team leader had an increased proportion of completed secondary surveys and formulated definitive plans. A different study evaluating pediatric trauma care found that the improved organization of a dedicated trauma team resulted in shorter times to CT scanning for head-injured patients, shorter time to surgery when necessary, and decreased times in the ER [50]. It has been reported that the establishment of organized trauma teams can be accomplished at very little cost [51].