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Autoamputation Of The Foot Following Treatment Of Chronic Leg Ulcer By Traditional Bonesetters

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.



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


Autoamputation; traditional bonesetting; prevention of complications.


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.

C:\Documents and Settings\DR. IKPEME\My Documents\My Pictures\2008-05-29, SIGN Nail\01.JPG

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,.


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.
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.


This is a peer reviewed paper 

Please cite as :Ikpeme A. Ikpeme : Autoamputation Of The Foot Following Treatment Of Chronic Leg Ulcer By Traditional Bonesetters

J.Orthopaedics 2008;5(4)e6





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