Complications of traditional bone setters (TBS) treatment of musculoskeletal injuries: experience in a private setting in Warri, South-South Nigeria

Introduction Complications arising from the practice of traditional bone setting is a major contributor to the challenges the orthodox orthopaedic practitioner in Nigeria faces. We share our experience at a multi-specialist private health facility in Warri, South-south, Nigeria. Methods Case notes of patients with musculoskeletal injuries who had prior treatment by traditional bone setters with resulting complications before presenting at our health facility for treatment were reviewed and relevant information extracted and entered in an already prepared proforma. Data were analysed using SPSS version 17 and results presented in form of means, percentages, ratios and tables. Results 43 cases were reviewed in a period of 8 years. There were 21 males and 22 females. The average age of patients was 44.8 ± 20.3 years. The most frequent age group affected was that of 40-49 years. 45.8% of the initial injuries were due to road traffic accidents while 39.5% resulted from falls. Femoral fractures and humeral fractures formed 20.4% and 14.8% of cases respectively. 40.8% of traditional bone setters complications observed were non-union of fractures of various bones followed by mal-union in 24.5% of cases. Conclusion The observed complications of traditional bone setters practice in this study were similar to those previously reported in the literature. These complications constitute a significant challenge to the orthopaedic practitioner in Africa with associated negative socioeconomic impact on our society. Government and other relevant stakeholders need to unite and take decisive actions to mitigate this problem.


Introduction
In many parts of the developing world, large proportion of fractures continue to be treated by traditional bone setters (TBS) who are readily available and often have a good local reputation [1]. In Nigeria, the practice of traditional bone setting is extensive and enjoys enormous patronage by the populace [2]. Up to 85% of patients with fractures are said to first present to traditional bone setters before presenting to orthodox hospitals [3]. This popularity is due to its long period of existence prior to the coming of orthodox practice, the ubiquity of the practitioners, affordability and acceptance of variable modes of payment (both in cash and kind) for services rendered in addition to wide spread belief in its effectiveness [2,[4][5][6][7]. The practice like many other traditional practices, is passed on from generation to generation along family lines in form of apprenticeship with occasional admission of persons outside the family line to learn the trade also as apprentices. There is usually no formal training curriculum, no basic qualification and the level of competence varies widely which accounts for most of the problems encountered with their practice. In addition, there is no legislative or government control of TBS practice in Nigeria today [3,[7][8][9][10]. Musculoskeletal injuries including fractures, sprains, dislocations etc, are manipulated (with skin scarification in some cases) and concoctions applied after which splinters are applied and the limb bandaged. In addition some traditional bone setters perform rituals with incantations to invoke divine assistance in the healing process. A few practitioners even go further to offer some form of orthodox care by administering analgesics, antibiotics and wound care in cases of open fractures with the assistance of some medical auxillaries [3,7,[11][12][13]. In spite of this popularity, the practice of traditional bone setting has been associated with unacceptable outcomes in many cases. Extreme cases include limb gangrene and death largely from sepsis/septicaemia, tetanus and anaemia. Other reported complications include: mal-union and non- The age group that presented most frequently was 40-49 years (23.3%) followed by 30-39 years (20.9%) Table 1. Traders and business persons were most frequent affected making up 27.9% of the patients followed by those schooling at various levels ( Table 1).
In terms of aetiology of initial injuries, 24 patients (55.8%) had injuries due to road traffic accidents followed by injuries from falls in 17 patients (39.5%). One of the patient (2.3%) sustained injury from assault and another one (2.3%) from to sporting activities.
Femoral fractures made up 20.4% of the initial injuries treated by traditional bone setters with resulting complications in this study Table 2. 40.8% of patients with TBS complications presented with non-union of fractures of various bones followed by mal-united fractures which formed 24.5% of cases. There were a total of 49 complications in 43 patients Table 3. Masterly inactivity was adopted for the patient with long standing brachial plexus injury after counselling on prognosis.

Discussion
Complications arising from the practice of traditional bone setting (TBS) significantly contribute to the challenges facing the Orthopaedic practitioner. [16]. These complications range from less severe ones like minor limb length discrepancies from mal-union of fractures with minimal effect on function, to major ones like limb gangrene and death. Our findings in this study are similar to those reported in the literature by previoius authors [2,7,8,14,15,17,18].  [5,10,15,[17][18][19]20]. More studies need to be done to corroborate this observation and explain possible reasons for it since the preponderance of males in previous studies had always been explained by the undisputed fact that males by their nature and activities are usually more prone to injuries. The average age of patients in this study was 44.8+20.3 years (ranged from 2-81 years). This mean age is much higher than that observed in some previous studies [17,19,20]. Average ages of 36.8 years, 32.3 years and 28 years have been reported respectively by Onyemaechi et al [20], Kuubiere et al [17] and El Hag et al [19] respectively. Similarly the age group most frequently encountered in this study is 40-49 years which is also much higher than those observed in other studies [15,17,19,20]. Older patients probably are more able to afford treatment in a private setting and would prefer the one on one attention obtainable in such a settings. The frequencies of various TBS complications of treatment of musculoskeletal injuries appear to vary from study to study. However, malunion and nonunion of fractures tend to feature significantly as being the most frequently observed complication in many previous studies including the present one. Kuubiere et al [17] and El Hag at al [19] reported mal-union as the most frequently observed complication in their series followed by non-union of fractures. Joint stiffness and infections both followed by mal-union of fractures were observed as the most frequently encountered TBS complications by Onyemaechi et al [20] and Nwandiaro et al [15] respectively. In this series fracture non-union was the most frequent complication followed by mal-union. A possible partial explanation for the observed variations may be the level of urbanisation in the environment of study, the nature and aetiology of the initial injuries, the competence and manner of practice of the traditional bone setters in a particular region and other socio-demographic factors which may need further investigations. Our study shows the femur as the most frequently fractured bone treated by TBS with resulting complications followed by the humerus and the forearm bones. This is similar to what has been reported by Kuubiere et al [17] from Ghana. In contrast, Nwandiaro et al [15] from North-Central Nigeria reported equal involvement of the femur, tibia/fibula, humerus and forearm bones while Onyemaechi et al [20] from the same region observed tibia as the commonest bone involved in TBS complications followed by the femur. Socio-demographic differences and other local factors may account for some of these variations. With regards to the aetiology of initial injuries treated by TBS with resulting complications in this study, more than 55% was due to road traffic accidents followed by falls. This is similar to findings by Onyemaechi et al [20] who reported that 69.4% of injuries in their study were due to road traffic accidents followed by falls in 27.8% of cases. On a general note, this finding is not surprising as road traffic accident has been reported in previous studies as the commonest cause of musculoskeletal trauma in our environment [21][22][23].

Competing interests
The authors declare no competing interests.

Authors' contributions
David Odoyoh Odatuwa-Omagbemi and Thomas Odafe Adiki designed the study, wrote the initial protocol and gathered data.       Elbow soft tissue injury 1 1.9