The contribution of musculo skeletal trauma to morbidity and disability in developing countries is often underestimated. As Head of Department of Surgery and Orthopaedics for 3 years at a non-paying hospital in Malawi/East Africa (one of the least developed countries according to UNDP), I analysed my operation log book of 658 cases. Although there are many specific and local factors influencing the picture, the main problems of trauma care in rural Africa become evident. Based on personal experience views on non-operative versus operative fracture treatment, indications, quality control and training are presented. First world standards, equipment and implants of yesterday are often the only ones available but they scarcely meet the demands of clinical practice in developing countries. Contemporary state-of-the-art knowledge lacks most of its material basis to be successfully introduced. However, transforming it into "appropriate technologies" is most rewarding not only for the individual trauma surgeon, but for the wider community within orthopaedics.