Dr Michael Okunola is a Consultant Orthopaedic and Trauma Surgeon with a sub-specialisation in Limb Lengthening and Deformity Correction at the Department of Orthopaedics and Trauma, University College Hospital, Ibadan. In this interview with SADE OGUNTOLA, he decried high incidents of limb amputation in children and Nigerians seeking care for fractures at the hospital.
IS traditional bone setting still a common practice in Nigeria?
Traditional bone setting is still a popular practice. In Nigeria, people’s belief in traditional medical practice is age-long. Just as there are traditional birth attendants, so are traditional bone setters, tending to injuries to the bones and musculoskeletal conditions in many communities. In Yoruba-land, they are popularly referred to as ‘atoegun’ or ‘aroogun’ meaning literally someone who rearranges or straightens a bent bone.
Unfortunately, people who patronise traditional bone setters, based on our experience working at UCH, Ibadan, as well as in other hospitals that provide orthopaedic care, have had a lot of bitter experiences. They are mismanaged, with some ending up with an amputated limb. In fact, most of the victims of the traditional bone-setter menace are children. They cannot decide for themselves when it comes to their choice of healthcare.
When children have musculoskeletal injuries or fractures to the bones of the limbs, they are taken to traditional bone setters. They apply some of their appliances to the affected limb too tightly. These end up cutting off the blood supply to the limb. Invariably, the limb begins to rot and will need to be amputated if taken to the hospital. There are quite a lot of children who have had their upper or lower limb amputated because they were first taken to traditional bone setters, where they were mismanaged.
How many cases of children’s limbs mishandled by traditional bone setters do you think you’ll encounter at UCH in the next week or month?
The statistics are quite disturbing; they come in seasons. You can have about six cases in a month. Currently, in our paediatric ward, we have about three children whose ages are between five and 10 years in this current session. They were admitted with rotten upper limb following mismanagement by the traditional bone-setters.
One child’s whole upper limb was amputated at the level of the shoulder. They all had minor injuries that would have taken probably one day of treatment at the hospital. They were taken to traditional bone setters and they came back to us with rotten upper limbs that had to be amputated. If we don’t do that, they will die from the infection and complications of the infection caused by the rotten limbs.
What really happened to these children? Were they cases of falls or what?
For children, what usually happens is that maybe in school they were playing, on a swing, or they were running up and down in the classroom, and then they fell and sustained injuries. Most of the time, it is the upper limb that is commonly affected in children. They may have a minor injury to the elbow or a simple fracture. It does not take much to treat them; just do an X-ray and then apply POP cast to the limb. In a few weeks, they are done with treatment. That is usually the history. But most often, they are counselled by the bystanders, friends, or relatives to take them to traditional bone setters. They end up with complications. When they eventually come to us, the limbs are rotten and the patients are dying. The only thing that we can do to save their lives is to remove the gangrenous or dead limbs.
For adults, fractures are usually caused by road traffic accidents and usually involve the leg. Aside from the fracture of the bone of the leg, there may also be wounds and bleeding. Ironically, when such cases are taken to traditional bone setters, they are managed the same way they manage all cases of broken bones in children. They tie their splints, and that further deprives the already injured limbs of blood supply, eventually the wound becomes infected and the leg becomes gangrenous, that is dead.
When they finally come to the hospital, we don’t have any other option but to take out the rotten leg because, at that time, we are battling to save the life of the patient.
Why two fractures of the bone not treated the same?
All fractures are not the same; likewise, treatment is subject to the exact injury. The ones that pose a lot of difficulty to traditional bone setters are those that also have wounds. They are prone to infection. The bone setters are not trained to administer antimicrobial drugs or treat the wounds so that infection will not complicate the fracture. Sometimes, the fracture will heal with the shortening of the limb or with deformities or may not heal at all, with patients not able to walk on the leg without support.
As orthopaedic surgeons, we know we cannot eliminate the practice completely, particularly with the current inadequate number of expertise in the country. But we can advise that all cases of fractures be taken to the hospital. When there are cases accompanied by wounds that cannot be managed successfully, they will then be sent to appropriate places where there are orthopaedic surgeons for adequate care.
What are red flags Nigerians should be watch out for when a fracture being managed by a traditional bone setter becomes complicated?
An excruciating pain and swelling a few hours after the application of the splint and their other remedies is usually how complications start. When the splint is too tight, it cuts off the blood supply to the limb. So, the limb begins to swell and the patient begins to feel more pain than necessary, even after medication. That is an indication that they need to see the right specialist for treatment.
It is for this reason that the primary healthcare centres should be the first point of contact for seeking medical care. Once they assess injuries of the patient and know they cannot handle them, they will refer them to the appropriate hospitals.
The long wait in many government hospitals, among other factors, scares people away to seek help for fractures. Given this predicament that many Nigerians find themselves in, what guidance would you offer?
I know we have a lot of challenges in health care. Ongoing researches on why people seek treatment from traditional bone setters after a limb injury have listed long waiting time, cost of treatment, delay before they attend to them and the belief that traditional medicine works better than orthodox. Also, people at the scene of the accident usually advise them to go to traditional bone setters. But taking into consideration many of those reasons, a lot of suggestions and measures that cut across the government, the hospitals and even the populace have been made. People need to be made aware of the fact that healthcare givers who are knowledgeable about fractures and the repercussions of mishandling them are the Orthodox orthopaedic in the hospitals; they are the ideal people to treat leg injuries.
The best way to manage these cases is to go to the right specialists. One way to overcome the challenges of shortage of orthodox orthopaedic doctors in our society at this time is to train the health workers at the primary care centre level to identify many of these limb injuries and fractures, and to treat uncomplicated ones. I strongly suggest this approach. Those injuries that are beyond what they can handle can now be referred to secondary and tertiary health care centres like UCH, where we have the available expertise to treat these patients.
Although some have suggested that we should train some of the traditional bone setters so that they can attend to some of the cases, this could complicate matters in our peculiar environment where strict regulations of health care practices is lacking at the moment. We observed some years ago that some traditional bone setter who attended a training organised at the Orthopaedic Hospital in Lagos took the advantage of the training to claim competency in treatment of all forms of injuries to the limb, in the process, causing more damage.
I will rather suggest we train the community health workers manning the primary healthcare centres to identify and treat uncomplicated fractures, like most of these fractures that children have from falls. We should incorporate treatment of simple fractures into health care delivery at primary health care level.
The cost of treatment is a reason some patronise traditional bone setters. Which is the cheaper option in the long run, traditional bone setter or orthopaedic specialists?
Assessing treatment at the hospital and from the appropriate specialist is the cheaper option. Traditional bone setters may not ask for an upfront payment for care; payment is done in installments. But, in the long run, it is not cheaper compared to what they would have paid, maybe upfront, when they had come to the hospital. So when the cost of attending to the complications of fractures by traditional bone setters is added, the cost of care from traditional bone setters becomes enormous. Of course, the cost of having an amputated limb, and sometimes loss of life due to severe infection from a dead limb as a result of the menace of the traditional bone setters is far beyond estimation.
Now, when people latch on to health insurance, this will further bring down the cost of accessing treatment for fractures in the hospital. Health insurance is a scheme that everyone should get enrolled in. This is a package for everyone to benefit from health care services, regardless of whether they are in the civil service or in the private sector. There are packages for artisans and traders as well. Health Insurance has brought the cost of treatment down significantly. So the cost shouldn’t be an issue again.
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