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Ikpeme A. Ikpeme*,
Anthony M.Udosen, Ngim E. Ngim, Paul Amah
*Department of Surgery, University of Calabar Teaching Hospital,
P.M.B. 1278, Calabar-Nigeria.
Address for Correspondence:
Dr. Ikpeme
A.Ikpeme,
GPO Box 1506,
Calabar, Nigeria.
E-mail: iaikpeme@yahoo.com
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Abstract:
Background: Traditional bonesetting is still widely
practiced in many parts of the developing world. The
complications are however enormous and gangrene is frequent.
Amputation is frequently offered as a salvage procedure to
ablate dead limb or to refashion a non-useful stump.
Autoamputation following traditional bonesetter’s gangrene is
rare and demonstrates the problems associated with erroneous
belief systems and late presentation common in Africa.
Objective:To present a rare case of autoamputation of the
foot following the treatment of a chronic leg ulcer by
traditional bonesetters.
Case Report: A 32 year farmer and mother of three(3)
presented with a six week history of loss of the (L) foot after
spending two(2) years in a traditional bonesetter’s practice.
She had gone to seek treatment for a Chronic leg ulcer and had
herbs tied onto the ulcer. Even as the infection spread, she
refused transfer to Orthodox care because of a belief that she
was attacked by evil spirits. She presented late in a poor
general state, with autoamputation of the (L) foot and extensive
gangrene and contractures of the (L) lower limb. Patient was
managed by above knee amputation and referred for prosthetic
rehabilitation.
Conclusion:The complications of traditional bonesetting are
severe but preventable. Cultural biases and erroneous beliefs
have entrenched the practice in many cultures. Strict
legislation and controls, health education and development of
adequate manpower are the ways to counter these practices and
prevent the complications that usually occur.
J.Orthopaedics 2008;5(4i)e6
Keywords:
Autoamputation; traditional bonesetting;
prevention of complications.
Introduction:
Amputation is the ablation of a diseased
limb. Autoamputations can result from trauma and dry gangrene in
portions of the extremity and to the authors’ knowledge have not
been reported following traditional bonesetting in Africa. The
commonly reported complications include wet gangrene
necessitating removal of the diseased extremity by a planned
surgical procedure.1,2
Traditional bonesetting is
widely practiced in many parts of the developing world.3 The
complications of traditional bonesetting are numerous.1,2,3The
cost of treating complications increases the overall cost of
care. In poor societies, this results in poor treatment outcome
since patients cannot afford expensive and sometimes extensive
corrective procedures; loss of productivity and perpetuation of
the poverty cycle.
African traditional bonesetting employs a
variety of methods including the application of herbal splints
with scarifications to treat injuries and limb conditions.
There is a predisposition to cellulitis which may progress to
gangrene. The belief in evil spirits as the cause of illness and
the African traditional bonesetter’s claims of supernatural
abilities often keep patients away from seeking orthodox care in
the early phases of complications. This report seeks to present
a severe and previously unreported complication of traditional
bonesetting in Africa.
Case Report :
Mrs. AM, a 32 year old mother of three
presented to our Hospital with a 6 week history of loss of the
left foot. She had noticed (L) foot swelling 6 years prior to
presentation followed by an ulceration on the medial aspect of
the dorsum of the foot and ascending cellulitis. Patient sought
treatment with a traditional bonesetter because she believed she
was attacked by evil spirits. Treatment consisted of herbal
concoctions in local gin and herbal dressings on the ulcer. The
(L) foot subsequently separated at the ankle and fell off.
At presentation, a diagnosis of
autoamputation at the (L) ankle was made with associated
extensive ulcers and sinuses; and flexion contractures of the
(L) knee and hip. She was in poor general condition and markedly
anaemic (Fig. 1). Patient was resuscitated and offered above
knee amputation of the (L) lower limb. The wound healed
primarily and patient was referred for prosthetic fitting.
Fig.1: Autoamputation (L) Foot With
Extensive (L) Leg Ulcers And Contractures
Discussion :
Traditional bone setting is immensely
popular in many parts of Africa and Asia3,5,6,. There have been
several literature on the severe complications that follow
traditional bonesetting especially from Africa3,4,6. Previous
Nigerian studies have documented the behavior and perception of
patients to traditional bonesetting3,7. In one of those studies
51% of patients chose traditional bonesetting for their injuries
because of a belief that traditional bonesetters were more
skillful than Orthopaedic surgeons. The complication rates
following this treatment intervention in that study was 61.2%3.
Inequitable access to
conventional healthcare by the majority of persons living in
developing countries has fueled a renewed interest in
traditional medicine3.A strong belief in evil spirits as the
cause of illness in Africa often encourages patients to seek
traditional medical interventions and contributes to late
presentation to orthodox facilities. In many parts of the
developing world, prosthetic technology and rehabilitation is
poorly developed. Amputees therefore hardly return to fully
productive lives. This leads to loss of income and perpetrates
the poverty cycle. Amputations are therefore better prevented by
judicious and early treatment of limb injuries.
In orthopaedic care, lack of
knowledge of regional anatomy, improper patient selection and
non understanding of fundamental principles like infection
prevention/control and soft tissue care can prevent optimum
outcomes when traditional practitioners treat limb injuries.
Developing economies need to invest more in health education,
effective legislation and control of traditional medical
practice to reduce the incidence of severe and preventable
complications1,6. Traditional bonesetting must be subject to
strict controls and countered by appropriate health education
and development of adequate numbers of skilled manpower for the
population. The role played by lack of awareness by traditional
bonesetters in the development of complications and the
advantages of exposing traditional bonesetters to education has
been documented in some reports 6,.
Conclusion:
Traditional bonesetting is often beset by
severe and preventable complications. Besides the loss of life,
loss of a limb is an extremely severe complication of this
treatment option. A Nigerian study showed limb injuries
mismanaged by traditional bonesetting accounted for 17% of
surgical amputations in a major centre.3 In developing economies
with fragile health systems, poor social support infrastructure
and rudimentary prosthetic and rehabilitation programmes,
amputation with the attendant stigma and socio-economic
implications presents significant challenges. Strict legal
controls and exposure of traditional bonesetters to some form of
injury/fracture care training will help reduce the complication
rates and contribute to primary injury care especially in rural
areas.
Reference :
1.Udosen A, Ikpeme I, Ngim N. Traditional Bone setting in
Africa: Counting the cost. Poster presentation. 5th SICOT/SIROT
Annual International Conference, Marrakech, Morocco. Abstract
Book; SIC 19-P28; 377 [Abstract].
2.Udosen AM, Ikpeme IA, Etiuma A, Egor S. Major Amputations at
the University of Calabar Teaching Hospital, Calabar, Nigeria.
Nig. J. Surg Sc 2004; 14(2): 60-3.
3.Ikpeme IA, Udosen AM, Okereke-Okpa I. Patients perception of
traditional bone setting in Calabar. Port Harcourt Med J.
2007:1:104-7.
4.Ogunlusi JD, Oluwadiya KS, Ogunlusi OO, Oginni LM, Oyedeji OA,
Ibligaami O. Acquired Boneless forearm as a complication of
traditional bonesetting. ORTHOPEDICS 2008; 31:288.
5.Oginni LM. Traditional bonesetting in Western Nigeria. In:
Biodun Adeniran (Ed). Cultural studies in Ile-Ife Institute of
African studies, Obafemi Awolowo University Ile-Ife. 1995;20
6.Eshete E. The prevention of traditional bonesetters gangrene.
J Bone Joint Surg Br. 2005;87-B:102-3.
7.World Health Organization (WHO). Tools for institutionalizing
traditional medicine in health systems in WHO Africa region.
WHO/AFRO/EDM/TRM/04.4. Brazzaville: WHO Africaregion.2004.
www.prometra.org/Documents/ToolsforInstitutionalizingTraditionalMedicine
in Health.pdf(accessed June 8, 2008): 7-8.
8.Onuminya JE. Performance of a trained traditional bonesetter
in primary fracture care. South Afr Med J (SAMJ) 2006;96(4):
320-22.
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