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Annals of African Medicine
Annals of African Medicine Society
ISSN: 1596-3519
Vol. 3, Num. 3, 2004, pp. 138-140

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
Reprint requests to: Dr. R. Habila Umaru, Departments of Orthopaedics, University of Maiduguri Teaching Hospital, P. M. B. 1414, Maiduguri, Nigeria. E-mail: Habilaumaru@yahoo.co.uk

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.
Methods: A retrospective study of data of patients that had amputation in University of Maiduguri Teaching Hospital between 1998 and 2002 was undertaken.
Results: A total number of 82 patients were entered into the study; there were 66 males and 16 Females (M.F ratio 4:1). Their ages ranged between 2 – 80 years with a median of 27 years. Seventy three percent of our patients were below the age of 45 years. The most common indication for limb amputation was gangrene arising from treatment of limb injuries by TBS 31.7%, followed by trauma 24.3% and malignancies 14.6%. Majority of the amputations were in the lower limbs and 35%of the patients had 2 – Stage operation. 
Conclusion: Preventable severe complications often arise from TBS treatment of musculoskeletal injuries. There is need for sustained health education to discourage patronage of TBS and encourage utilization of modern health service. Basic training for TBS in safe splintage and early identification of signs of ischaemia may not be out of place.

Key words: Limb amputation, inappropriate traditional splintage

INTRODUCTION

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

Indication

No.

%

Traditional splintage

26

31.7

Trauma

20

24.3

Malignancies

12

14.6

Diabetic foot

6

7.3

Severe burns

6

7.3

Vascular disease

5

6.1

Snake bite

2

2.4

Ainhum

2

2.4

Fungal infection (madura foot)

2

2.4

Iatrogenic

1

1.2

Total

82

100

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

Level of amputation

No.

%

Above knee amputation

28

34.1

Below knee amputation

25

30.5

Finger amputation

10

12.2

Above elbow amputation

9

10.9

Below elbow amputation

5

6.1

Toe amputation

4

4.9

Through knee

1

1.2

Total

82

100

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

Type of injuries

No.

%

Simple fracture

13

50

Open fracture

10

38.5

Soft tissue injuries (no fracture)

3

11.5

Total:

26

100

Table 4: Age of patients presenting with traditional bone setters gangrene

Age(years)

No.

%

<15

14

53.8

15 – 29

4

15.4

30 – 44

8

30.8

45 – 59

-

0

> 60

-

0

Total

26

100

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

  1. Tooms RE. General principles of amputation. In: Campbell’s operative orthopaedics. Mosby, St.Louis. 1998; 521-530.
  2. Magee RA. Amputation through the ages the oldest surgical operation. Aust NZ Surg 1998; 68:675-678.
  3. Olaolorun DA. Amputation in general practice. Niger Postgrad Med J 2001; 8: 133-135.
  4. Garba ES, Deshi PJ, Ihejirika KE. The role of traditional bone setters in limb amputation in Zaria. Nigerian Journal of Surgical Research 1999; 1: 21-24.
  5. Yakubu A, Muhammad I, Mabogunje O. Limb amputation in children in Zaria, Nigeria. Ann Trop Paediatr 1995; 15:163-165.
  6. Thanni LOA, Akindipe JA, Alausa OK. Nigerian Journal of Orthopaedics and Trauma 2003; 2: 112-115.
  7. Muyembe VM, Muhinga MN. Major limb amputation at a provincial hospital in Kenya.
  8. East Afr Med J 1999; 76: 163-166.
  9. Antonio L. The reasons for amputation in children (0-18yrs) in a developing country. Trop Doct 1994; 24: 99-102.
  10. Uwin N. Epidemiology of lower extremity amputation in centres Europe, North America and East Asia. Br J Surg 2000; 87:328-337.

Copyright 2004 - Annals of African Medicine

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