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Annals of African Medicine, Vol. 3, No. 3, 2004, pp. 138-140 ROLE OF INAPPROPRIATE TRADITIONAL SPLINTAGE IN LIMB AMPUTATION IN MAIDUGURI, NIGERIA R. H. Umaru, B. M Gali* and N. Ali* Departments of Orthopaedics and Surgery,* University of Maiduguri Teaching
Hospital, Maiduguri, Nigeria Code Number: am04034 ABSTRACT Background: University of Maiduguri Teaching Hospital a
major referable Centre in Northeastern Nigeria over the years has been faced
with management of complications of limb injuries arising from treatment
of limb fractures and injuries by the traditional bone setters (TBS). This
study is therefore aimed at determining the role of inappropriate traditional
splintage in limb amputation and proffer interventional strategies to curb
the menace. Key words: Limb amputation, inappropriate traditional splintage Amputation is the most ancient of all surgical procedures and has been practiced for punitive, ritual and therapeutic reasons. 1, 2, 3 The incidences of different pathologies leading to limb amputation vary from one place to the other. 4 In our environment preventable aetielogical factors like gangrene arising from traditional splintage of limb injuries by traditional bone setters (TBS) are the commonest indications for amputations of limbs in young individuals. Amputation in developing countries could be devastating due to associated psychosocial trauma3, 4 and dearth of rehabilitation facilities. In light of the morbidity associated with this condition, this study was carried out to determine the role of inappropriate traditional splintage in limb amputation in Maiduguri and make recommendation that could reduce the unnecessary loss of limbs. PATIENTS AND METHODS This is a retrospective review of 82 amputations done between January 1998 and December 2002 at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Patients whose records were in adequate were excluded from the study. RESULTS The patients were aged 2 - 80 years (median 27 years). Seventy three percent of the patients were below 45 years. There were 62 males and 20 females giving a male to female ratio of 3:1. The indications for amputation were as follows (Table 1) gangrene resulting from traditional splintage of limb injuries and fractures by TBS 26 (31:7%), Trauma (falls, road traffic accident, gun shot injuries, and industrial accidents) 20 (23.4%), malignancies 12 (14.6%), while diabetic foot and severe burns 6 (7.3%) each. Table 1: Indications for limb amputation
Thirty five percent of our patients had 2 stage operation, initial guillotine and later stump revision. The levels of amputation were as follows: Above the knee amputation (AKA) 28 (34.1%), below the knee amputation (BKA) 25 (30.5%), above elbow amputation (AEA) 9 (10.9%), finger amputation 10 (12.2%). Below elbow amputation (BEA) 5 (6.1%).Toe amputation 4 (4.9%) and through knee 1 (1.2%) (Table 2). Table 2: Final level amputation
The types of limb injuries sustained by 26 patients managed by the TBS is shown in table 3. The age distribution of these 26 patients is shown in table 4. Table 3: Type of injuries sustained by 26 patients presenting with traditional bone setters gangrene
Table 4: Age of patients presenting with traditional bone setters gangrene
DISCUSSION In this study the bulk of the patients were young males below 45 years with children contributing a significant proportion 26(31.7%). The major reasons for amputations were trauma and traditional bone setters gangrene (TBS gangrene) resulting from in appropriate traditional splintage of limb injuries. The splintage is undertaken immediately after limb injury with or without fractures. The process of splintage involves manipulation and scarification of the affected area to drain bad blood then application of concoction through the bleeding points, bamboo sticks are than arranged round the affected area, tightly held in place with pieces of cloth. This type of splintage does not make allowance for tissue oedema and the scarification technically turns even simple fractures into open variety, hence ischaemia and subsequently wet gangrene is often the end result. The involvements of more young males is not surprising as they are more adventurous in the active years and engages in more injury prone activities compared to the females. The high rate of amputation among children 26 (31.7%) is more of a local problem, where childhood labour is rampant to complement parents income in a poverty stricken society exposing them to injuries which are preferably managed by TBS. The study is in agreement with a recent report from Zaria, Northern Nigeria4, where the peak age incidents was 28 years and the commonest indications for amputation being TBS gangrene and trauma, a fact which correlated with the findings of an earlier study in children from the same institution5. Our findings differ from that of Thanni6 who reported gangrene resulting from local splintage as the least common of complications of traditional bone setters in southwestern Nigeria. This may not be unconnected with process of splintage in that region, which is removed frequently for re-manipulation and topical applications6 this invariably allows for recovery of ichaemic tissue. In contrast to the practice in our series splint once applied is never removed until after the prescribed days normally in weeks, based on the age of the patient. Majority of our amputations were performed in the lower limb (70%); this is similar to findings of other authors 3,7;8 which confirms the earlier findings that lower extremities are injured more often than the upper extremities and diabetic gangrene is common on the lower extremities than elsewhere on the body 1,3,9. Amputation of an irreversibly damaged or diseased limb is truly the first step in returning a patient to a normal productive life1, but of equal importance is the rehabilitation and reintegration. This is the most challenging aspect of management of amputees in our experience, Orthotics and Prosthetic devices are unavailable and where available are unaffordable by most patients who depend on crutches and walking sticks, these group often fail to get back to pre-amputation independent life3, 6. It is in line with this psychosocial problem and unnecessary lost of limbs, we suggest that; Othotic and Prosthetic units should be established in more centers across the country to facilitate the rehabilitation of the amputees. Campaign against child labour should be intensified to reduce exposure of children to injury prone environment. There is need for sustained health education to discourage patronage of TBS and advertisement of their services on print and electronic media should be discouraged if not out rightly prohibited by relevant agencies. In the interim the Medical regulatory bodies should design programme that can give basic training to TBS for safe application of splints and early identification of signs of ishaemia. Finally, progressive improvement in the economy will complement these actions to reduce the number of TBS and increase utilization of modern orthopedic services exclusively6. REFERENCES
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