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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 16-20

Management of complications of age-long tradition presented at Ado-Ekiti, Southwest Nigeria


1 Department of Surgery, Ekiti State University, Ado Ekiti, Nigeria
2 Department of Accident and Emergency, Victoria Hospital, Castries, St. Lucia
3 Department of Surgery, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria

Date of Web Publication19-Nov-2015

Correspondence Address:
Dr. Moruf Babatunde Yusuf
Department of Surgery, Ekiti State University, Ado Ekiti
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1597-1112.169812

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  Abstract 

Context: In the developing countries, traditional bonesetters (TBS) continue to ply their trade, and they treat a large proportion of patients with fractures and dislocations. They are known in the hospital practice because of complications arising from their practice that present in the hospital.
Aims: To look at the pattern of complications of TBS limb injuries management that presented at our center; factors influencing the decision to patronize TBS and treatment outcome of the complications.
Subjects and Methods: A descriptive study designed to look at the TBSs complications that presented at our hospital between May 2011 and April 2014.
Results: Forty-five patients were managed after TBS intervention. Road traffic crash accounted for 64.4% of their injury. Relations (47.8%) and friends (34.8%) influenced largely, decision to patronize TBS. Thirty-three (61.1%) went to TBS believing they have better outcome. Fracture nonunion accounted for the highest complication (53.3%). Most of the patients had operative intervention. Twenty-eight (68.3%) regained full limb functions, whereas 13 (31.7%) had impaired functions.
Conclusions: Large percentage of the patients believed TBS have better outcome; and their complications were treated largely by surgery to regain limb functions.

Keywords: Age-long tradition, bonesetters, complications


How to cite this article:
Yusuf MB, Popoola SO, Oluwadiya KS, Ogunlusi JD, Ige OE. Management of complications of age-long tradition presented at Ado-Ekiti, Southwest Nigeria. Afr J Trauma 2015;4:16-20

How to cite this URL:
Yusuf MB, Popoola SO, Oluwadiya KS, Ogunlusi JD, Ige OE. Management of complications of age-long tradition presented at Ado-Ekiti, Southwest Nigeria. Afr J Trauma [serial online] 2015 [cited 2020 Oct 25];4:16-20. Available from: https://www.afrjtrauma.com/text.asp?2015/4/1/16/169812


  Introduction Top


Traditional bonesetting (TBS), an age-long tradition, is described as the most ancient healing art.[1] Bonesetting and TBS go back for thousands of years, before there was an organized medical profession. Bonesetting was absorbed into orthopedic surgery approximately 120 years ago through a fortuitous accident of history, geography, and family connections. TBS in the Western nations were gradually replaced by orthopedist trained surgeon to treat fractures and dislocations. In the developing countries, TBS continue to ply their trade and they treat large proportion of patients with fractures and dislocations.[1]

The TBS are known in the hospital practice for complications arising from their practice which present in the hospital for rectification.[2] These complications range from traumatic osteomyelitis, malunion, nonunion and/or limb shortening, to gangrene necessitating amputation.[2],[3] There could be an occasional loss of life.[4] Regardless of these complications, many patients still prefer TBS home after taking their discharge from orthodox care.[5]

The complications result because of inadequate diagnostic technique and inappropriate method of fracture treatment.[6] This study aimed at reviewing the pattern of complications of limb injuries managed by TBS presented at our facility, factors influencing decision to patronize TBS and treatment outcome of the TBS complications.

A descriptive study designed to look at the complications of limb injuries managed by TBS that presented at Ekiti State University Teaching Hospital, Ado Ekiti, Southwest Nigeria. Record of patients that have visited TBS before presented for care between May 2011 and April 2014 were reviewed. Patients biodata, causes of injury, places of treatment, reasons and who initiated visiting TBS for treatment, reason(s) for leaving TBS, post-TBS intervention diagnosis, treatment offered in the hospital, outcome of hospital treatment and duration of follow-up were obtained for evaluation.

Data were analyzed using Statistical Package for Social Sciences Software (SPSS Inc., Chicago, Illinois, USA) and Microsoft Office Excel. Frequency distributions of variables were found and results were presented in Tables.


  Results Top


During the study period, 810 patients were admitted and managed for limb injuries, 131 left against medical advice during same period, and 45 (5.6% of patients managed for limb injuries) presented after TBS interventions. The ages of patients with TBS interventions ranged from 3 to 85 years with mean age of 38.3 ± 20.7 years, 29 were male and 16 were female with male: female of 1.8:1. Twenty-nine (64.4%) of the patient had their injury from road traffic crash; 14 (31.1%) from fall; and 1 (2.2%) each from assault and industrial accident. The time interval between the injury and presentation at the study center for rectification ranged from 1 to 275 weeks, with median of 17.00 weeks.

All strata of educational level patronize TBS. Twelve (26.7%) had primary education; 19 (42.2%) had secondary education; 12 (26.7%) had tertiary education; and 2 (4.4%) had no formal education. Femoral fractures constituted the largest group (37.8%), 1 patient each had clavicular fracture, multiple fractures and brachial plexus injury [Table 1]. Twenty-two (48.9%) of the patients, presented directly to the TBS place from the site of the injury, whereas 23 (51.1%) presented first at an orthodox facility before taken their discharge, with mean duration of stay of 8.2 ± 18.9 days. Reasons for leaving orthodox care include relations pressure (34.8%), believe more in TBS (17.4%), dissatisfaction with orthodox care (21.7%), high cost of hospital care (17.4%), patient was on transit (4.3%), and strike by health workers (4.3%).
Table 1: Types of the injury

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As shown in [Table 2], more than half of the patients (53.3%) presented with fracture nonunion, 4 (8.9%) had neglected dislocations [Figure 1] and 4.4% had gangrenous limb [Figure 2] and [Figure 3]. Twenty-two (47.8%) patients were advised by relations to patronised TBS; 16 (34.8%) by friends and 8 (17.4%) on personal preference. A patient was advised by both relations and friends. The reasons for the initial preference in TBS care included; believed they were better in bone treatment, 61.1% [Table 3]. As shown in [Table 4], operative treatment; which included open reduction and internal fixation with plate and screws or intramedullary nail ± bone grafting (53.3%), open reduction and external fixation ± limb lengthening (8.9%); was an important option in rectifying the complications of TBS treatment. Two (4.4%) of the patients had limb amputation and 4 (8.9%) defaulted from continue care.
Table 2: Post-TBS treatment diagnosis

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Figure 1: Plain radiographic film showing neglected shoulder dislocation undiagnosed by traditional bonesetters

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Figure 2: Neglected gangrenous limb from tight traditional bonesetter's splint used to treat a patient with femoral shaft fracture by traditional bonesetters

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Figure 3: Gangrenous forearm from tight traditional bonesetter's splint used to treat humeral supracondylar fracture

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Table 3: Reasons for patronizing TBS

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Table 4: Rectifications offered for the presented complications

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There was no postintervention complication in 37 (90.2%); 2 (4.9%) patients had persistence neurological deficit; and 1 patient each (2.4%) had flap necrosis, and persistence bleeding from wound site. Twenty-eight (68.3%) of the patients regained full function of the limb; 6 (14.6%) had reduced range of motion across adjacent joint; 4 (9.8%) had limb shortening that will require limb lengthening; 2 (4.9) had persistent of neurological deficit; and a patient was referred to another tertiary institution because of persistent bleeding from wound site for better evaluation and treatment.

Patients were followed up for 21–147 weeks with a mean of 74.82 ± 39.2 weeks.


  Discussion Top


In many parts of the developing world, a large proportion of fractures continue to be treated by TBS, who are readily available and often have a good local reputation.[7],[8] While many fractures do heal properly with traditional treatment,[8] some do come down with complications. It is these complications that patients bring to hospitals for rectification.

We do not know how many patients are successfully treated by TBS, since not all patients treated by TBS report back to the orthodox hospital.[9] This means that TBS could be achieving some success or patients are adapting to the impaired function, or they are seeking treatment elsewhere.

The effect of culture and belief in TBSs are overwhelming, making nonsense of patients' level of formal education.[10] From our study, patronage cut across all education strata and majority of the patients had at least secondary education. Patients also leave the orthodox facility to seek TBS's care or present directly to TBS place from the site of injury. From our study, 48.9% presented directly at the TBS place whereas others had initial care at the orthodox facility. This is comparable with finding of 51.1% presented directly at TBS place by Idris et al.[9] in a cross-sectional study conducted in Aljazeera and Khartoum province, both in Sudan.

The decision to patronize TBS is influenced greatly by third parties. Patients are often emotionally vulnerable following major trauma, and may consequently succumb to third party influences.[10] Third party decision to patronize TBS accounted for 82.6% in this study, which is comparable to 75% in Solagberu [10] study, but higher than 68.1% in Idris et al.[9] study on why people prefer TBS in Sudan. There are varied reasons why patients patronized TBS care; these include their belief that TBS are better in fracture treatment; achieve faster fracture healing; are easily accessible, and are more affordable.[10],[11],[12] The most prominent reason for preference in TBS is the belief of being better in fracture treatment than orthodox practitioners.[9],[13] From our study, 73.3% of the patients initially belief that TBSs were better in bone treatment, however, failed treatment gave them a rethink.

Methods of fracture treatment could account for the problems from TBSs intervention. Indiscriminate application of tight splint often results in tourniquet effect with the subsequent development of compartment syndrome, ischemia and limb gangrene. Where intermittent massaging and pulling are used as a mode of treatment, they usually lead to heterotrophic ossification and nonunion.[8],[14] The most common problem from TBS intervention in this study is fracture nonunion (53.3%), followed by malunion (11.1%). This is comparable to the finding of nonunion (55.1%) and malunion (41.4%) by Ogunlusi et al.[11] This contrasts the finding of malunion (58.3% and 38.3%) and nonunion (25% and 20.0%) by OlaOlorun et al.[13] and Solagberu [10] respectively, in previous studies.

The complications from TBS intervention pose a major challenge to orthopedic surgeon as they form a large number of cases seen; they also create problems in term of management.[9] Operative treatment is crucial, in the rectification of these problems. Thirty-four (75.5%) of the patients had one form of surgery or the other. Two patients presented with "traditional bonesetters' gangrene" for which they had an amputation, and they were a loss to follow-up and the need for prosthesis could not even be discussed with them. The defaulted patients were, probably, still looking for cheaper or nonoperative alternative for their problems. A large proportion of the patients had satisfactory outcome while some will still need to be subjected to further surgery, in the form of limb lengthening, arthrolysis, nerve or tendon transfer.

The behavior and believe of patients in developing countries toward TBS are fairly similar and pattern of TBS complications presented at our center are comparable to report from other centers. Larger proportion of patients with fractures that patronized TBS did so after taking their discharge from orthodox care. One of the factors responsible for this is the out of pocket financing of definitive operative fracture care for these patients. If patients' fractures are fixed within 24 h without recourse to pay out of pocket, as it is practiced in most advanced countries, there would be no need for them to leave against medical advice universal health insurance coverage will make such level of care affordable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Green SA. Orthopaedic surgeons. Inheritors of tradition. Clin Orthop Relat Res 1999;:258-63.  Back to cited text no. 1
    
2.
Oginni LM. The use of traditional fracture splint for bone setting. Niger Med Pract 1999;24:49-51.  Back to cited text no. 2
    
3.
Solagberu BA. The complications seen from the treatment by traditional bonesetters. West Afr J Med 2003;22:343-4.  Back to cited text no. 3
[PUBMED]    
4.
Nwankwo OE, Katchy AU. Limb gangrene following treatment of limb injury by traditional bone setter (Tbs): A report of 15 consecutive cases. Niger Postgrad Med J 2005;12:57-60.  Back to cited text no. 4
    
5.
Popoola SO, Onyemaechi NOC, Kortor JN, Oluwadiya KS. Leave against medical advice (LAMA) from in-patient orthopaedic treatment. SA Orthop J 2013;12:58-61.  Back to cited text no. 5
    
6.
Garba ES, Deshi PJ. Traditional bone setting: A risk factor in limb amputation. East Afr Med J 1998;75:553-5.  Back to cited text no. 6
    
7.
Eshete M. The prevention of traditional bone setter's gangrene. J Bone Joint Surg Br 2005;87:102-3.  Back to cited text no. 7
    
8.
Onuminya JE. Performance of a trained traditional bonesetter in primary fracture care. S Afr Med J 2006;96:320-2.  Back to cited text no. 8
    
9.
Idris SA, Mohammed OB, Basheer ES. Why do people prefer traditional bonesetters in Sudan? Sudan JMS 2010;5:199-205.  Back to cited text no. 9
    
10.
Solagberu BA. Long bone fractures treated by traditional bonesetters: A study of patients' behaviour. Trop Doct 2005;35:106-8.  Back to cited text no. 10
    
11.
Ogunlusi JD, Okem IC, Oginni LM. Why patients patronize traditional bone setters. Int J Orthop Surg 2007;4.  Back to cited text no. 11
    
12.
Onuminya JE, Onabowale BO, Obekpa PO, Ihezue CH. Traditional bone setter's gangrene. Int Orthop 1999;23:111-2.  Back to cited text no. 12
    
13.
OlaOlorun DA, Oladiran IO, Adeniran A. Complications of fracture treatment by traditional bonesetters in southwest Nigeria. Fam Pract 2001;18:635-7.  Back to cited text no. 13
    
14.
Dada AA, Yinusa W, Giwa SO. Review of the practice of traditional bone setting in Nigeria. Afr Health Sci 2011;11:262-5.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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