Medical experts in the country have said that complications arising from the practice of traditional bone-setting is a major contributor to the challenges that orthopaedic practitioners face in Nigeria.
They said the activities of traditional bonesetters constitute a serious challenge to orthopaedic practice, with associated negative socio-economic impact.
This is even as some researchers recommend that traditional bonesetters not only be taught certain injury management techniques, but to also be incorporated into the Nigerian healthcare system.
A study, titled, ‘Traditional Bonesetters and Contemporary Orthopaedic Fracture Care in a Developing Nation: Historical Aspects, Contemporary Status and Future Directions,’ published in The Open Orthopaedics Journal, suggests that bonesetters be allowed to fill perceived void created by the severe lack of surgeons.
The study, done by four researchers, noted that bonesetters are primarily located in rural areas where they best care for underserved communities.
“In an integrated scheme, bonesetters would manage fractures for which they can achieve acceptable outcomes, referring others to local hospitals,” the researchers said; adding, “An integrated model of fracture care is applicable in all developing countries where bonesetters perform a large proportion of fracture care.”
Also, a more recent study, published in Human Resources for Health last March, suggested that traditional bonesetters could be trained as technicians in order to make the practice safe.
The study demonstrated the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and treatment outcomes.
“This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other Low Middle-Income Countries where TBS are widely patronized,” the researchers say.
Another research published by BioMed Central, also in March, shows that TBS provide the majority of primary fracture care in Nigeria and their services are commonly associated with complications.
The research, led by Ndubuisi Onu Onyemaechi noted that TBS receive no formal training in modern orthopaedic care, but mostly acquire informal training from family members as a part of ancestral heritage.
The researchers lament that the practice of bone setting is unregulated and lacks the basic scientific principles of fracture management as well as infection prevention and control.
“Subsequently, the treatment of bone and joint injuries by the TBS has been reported to be associated with some complications such as malunion, non-union, gangrene, chronic osteomyelitis, Volkmann’s ischaemic contracture, and joint stiffness.
“Despite the shortcomings in the training and outcomes of fracture treatment by the TBS, they enjoy high patronage and confidence in their communities.
About 70–90 percent of primary fracture care is provided by the TBS in many rural communities in Nigeria,” the researchers noted.
The lack of sufficient orthopaedic surgeons forces many people to patronise the TBS, the researchers agree.
Speaking to our correspondent, a professor at the Department of Orthopaedics and Trauma Surgery, Ahmadu Bello University, Zaria, Mike Ogirima, said, “If the complications from patronising traditional bonesetters are eradicated, it will be easy to manage more than 50 percent of orthopaedic cases.”
Less than 600 surgeons to over 200m population
Ogirima, who is the former President of the Nigerian Orthopaedic Association, however, said there are barely 600 orthopaedic surgeons in the country available to a population of over 200 million.
“Traditional bonesetters are everywhere, unlike orthopaedic surgeons. In Nigeria, we can barely boast of 600 orthopaedic surgeons.
“But in every village in Nigeria, you will have a bonesetter. Their method of treatments are crude, it does not follow any scientific principle,” he noted
He said the disadvantages of patronising the TBS outweigh the advantages.
“There are no national statistics, but when I see 10 cases of orthopaedic surgery, virtually 90 percent have visited or consulted a TBS.
“These cases cut across joint pain, fracture, rheumatism. Even the educated ones, including professors, patronise TBS,” Ogirima said.
He said though traditional bone setting is an age-long practice, its practitioners have refused to accept the scientific methods of bone treatment.
“That is why the consequences of patronising them are great. It’s either they maim the limb or cause infection to the patient, which may ultimately kill the patient.
“This is apart from the deformity they present to the orthodox hospital,” Ogirima added.
Also, an Orthopaedic Surgeon at the National Orthopaedic Hospital, Igbobi, Lagos, Dr. Uyilawa Okhuaihesuyi, said the complications patients present with at the hospital are no-union of fractures, malunion, joint dislocations, and gangrene, among others.
According to him, the cases are seen among all age groups who are mostly victims of road traffic accidents.
Okhuaihesuyi, who is also the President of the National Association of Resident Doctors, said the increasing complications like gangrene associated with TBS is a result of tightly wrapped stick splint application.
“When they go to the TBS, they are not educated about what the problems are and they think they cannot afford the treatment; but in the long run, the TBS is even more expensive because, by the time you sum the money they spend at the TBS, it will be more than the money they would have spent at the hospital.
“By the time they present at the hospital, some have complications like malunion, needing further treatment, and some may lose their legs.
“Some go to TBS and get their legs tied and this locks up the blood supply. When the limb is tied too tightly, it locks up the blood supply and the leg dies.
“When they put a stick around the limb that is fractured, the amount of pressure used to tie it locks up the blood supply and the limb loses colour and becomes gangrenous.
“In those that have open injuries, they tend not to understand that they have to use antibiotics and dress the wound daily. With that, the wound becomes infected and it spreads around the leg which can lead to gangrene,” Okhuaihesuyi said.
Speaking in same vein, Ogirima said, “It is known that if there is a fracture, they will heal naturally; but joining them to maintain the alignment so that that part can be functional with a good cosmetic appearance remain the difference between the TBS and the orthopaedic surgeons.
“The complications we see arise from the methods they use. Some fractures will never join if you do not operate on them; particularly the fracture close to the joint.
“There are some injuries that I have attended to, especially the dislocation of joint and if you don’t do an X-ray to confirm what you have done and you think by massaging it, you have healed the dislocation, you have maimed that joint. So, the joint will become stiff for life and become useless.
“If they introduce infection through the skin, it spreads to the system which will knock off the entire system, leading to septic shock and, ultimately, death.
“Death of a patient can result from their actions. Most of the amputations done are basically from the mishap of the TBS. So, there is a wide spectrum of effects of TBS that we see.”
On the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment, Ogirima said there is a mixed opinion among the orthopaedic surgeons.
“Some will say we need to educate them, but another group will say these people don’t believe in your scientific method of treatment.
“But by and large, they need to be educated, they need to be taught the basic do’s and dont’s about the musculoskeletal system when they are affected. They should know what to eat and what not to eat,” the former president of the Nigerian Medical Association said.
The experts say all stakeholders, including the government, must come together and find a lasting solution to the avoidable menace.
Okhuaihesuyi added that government and other relevant stakeholders need to unite and take decisive actions to mitigate this problem.
“There is nothing like having proper healthcare and if they have to visit a TBS, they need to know that there are complications like gangrene, ascending cellulitis, infections, which will demand more money.
“Government and stakeholders need to educate the TBS and ensure that they know their limits.
“They should know when their limits end and know when to refer to the hospital,” he said.
Ogirima, however, said “the government should train more personnel and increase their capacity so that the nation can have more people who are trained to take care of musculoskeletal pathologies.
“We need more orthopaedic surgeons in Nigeria. We need to equip our orthopaedic hospitals, we need to get modern technologies,” he said.
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