Hemipelvectomy following fracture mismanagement by traditional bone setters: a case report

¹Kampala International University, Ishaka-Bushenyi, Uganda, ²Department of Orthopedics, Muhimbili University, Dar es Salaam, Tanzania, ³St. Joseph's Hospital Kitovu, Masaka, Uganda

^&Corresponding author
Godfrey Kimbugwe, St. Joseph's Hospital Kitovu, Masaka, Uganda

Introduction    

Traditional bone setters are individuals who are recognised by their communities as competent enough to provide healthcare for various musculoskeletal problems, including fractures and dislocations, by using herbs, animal and mineral substances, or other methods [1]. Traditional bone setting (TBS) is widely practised in developing countries, though the principles differ between communities [1,2]. However, there are certain characteristics that are common to all. The traditional bone setters are usually uneducated without any medical background, and they rely mainly on inheritance, experience, and spiritual intuition [2]. The practice of TBS is usually preserved as a family tradition and is passed from generation to generation. The practice is usually within the family circle from father to son, and sometimes extended family members and others may be trained through apprenticeship [3,4]. They use bamboo sticks, rattan cane or palm leaf axis with cotton thread, or old cloth to splint the dislocated or fractured limbs [2].

The challenge of the orthopaedic surgeon is the attendant complications that are presented after the patient has been mismanaged by the bone setters [5]. Some of these complications include limb gangrene following very tight local splints, malunion, nonunion, osteomyelitis, contractures, and limb length discrepancies [5-7]. Despite these complications, the demand for TBS has increased, with some patients on admission in orthodox hospitals opting for treatment by a traditional bone setter instead [8]. We present a case of a 17-year-old with mismanaged open fractures by a bone setter, resulting in gangrene and hence a hemipelvectomy.

Patient and observation     

Patient information: a 17-year-old male with no prior medical history.

Clinical findings: the patient presented with a 1-week history of purulent discharge from the right lower limb following a road traffic accident that happened 2 weeks before admission.

Timeline of current episode: he reports that he fell off a moving motorcycle on which he was a passenger on the road and was run over by a speeding truck. He reported loss of consciousness for several hours and sustained multiple fractures of his right lower limb. He was taken to a local hospital, where care for his other injuries was provided. However, consent to manage the fractures was denied, with a plan to manage them by a traditional bone setter. One week before admission, the patient developed purulent discharge from wounds on the right lower limb with loss of sensation, fever, anorexia, and generalised body weakness.

Diagnostic assessment: at the time of admission to our hospital, the patient was examined and found to have moderate pallor, moderate jaundice, and was generally sick looking with a systolic blood pressure of 80 mmHg with an unrecordable diastolic pressure, pulse rate of 136 bpm, oxygen saturation of 89% on room air, temperature of 38.6°C, and respiratory rate of 40 breaths/min. Physical examination revealed an edematous right lower limb with infected wounds all over the limb extending to the right iliac fossa with foul-smelling pus. The patella, distal femur and proximal tibia were exposed. All sensations and dorsalis pedis and posterior tibial pulses to the right lower limb were absent with no mobility (Figure 1).

Diagnosis: a diagnosis of right lower limb necrosis was made.

Therapeutic interventions: the patient was resuscitated with intravenous fluids and blood transfusions. Analgesics and broad-spectrum antibiotics were given with some improvement in vital signs. Due to the extensive nature of the infection, a decision was made to perform a right hip amputation. The patient was taken to the operating theatre and placed under general anaesthesia. Intraoperatively, a limb assessment was performed that noted a necrotic right lower limb with involvement of the hip joint and lower abdominal wall. The limb was disarticulated at the right hip joint, and generous debridement was done, sparing only the viable muscle fibres. The wound was irrigated with normal saline, dressed, and resuscitation continued on the surgical ward (Figure 2). Serial debridements were performed in the subsequent days. During the second debridement, we found exposed and necrotic right iliac bone with a fracture at the right pubis with additional loss of soft tissue. A right hemipelvectomy and further debridement were then performed (Figure 3). Additional necrotic tissue was removed, and repeated drainage was performed during subsequent debridements. Drains were used to aid wound healing by reducing any fluid collections within the wound.

Follow-up and outcome of interventions: granulation tissue began to form around the amputation wound. Retention sutures were placed to begin apposing the muscle flaps together and aid in wound closure (Figure 4). The patient was given crutches for ambulation and psychosocial counselling. He was later discharged from the hospital after 2 months.

Patient perspective: "I am grateful that I can now get back to work."

Informed consent: written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Discussion     

Despite the presence of modern healthcare services, TBS remains widely practised across Africa. Its appeal spans all segments of society, including the young, the elderly, the educated, and the affluent [9]. In this case, our patient sustained injuries from a road traffic accident and initially received medical attention at a hospital. However, his family declined definitive fracture treatment in favour of care by a traditional bone setter. In Uganda's rural areas, as in many parts of Africa, TBS is a common method for managing fractures. Unfortunately, this practice is associated with high rates of complications, including severe infections and limb gangrene [1]. While the exact prevalence of amputations resulting from TBS in our region is unknown, studies from other settings have reported that 63-65% of major limb amputations are linked to complications from TBS care [10].

Children are disproportionately affected, with gangrene more frequently occurring in younger patients, particularly involving the lower limbs, with a median age reported around 11 years [10]. Our patient, a 17-year-old, developed sepsis and subsequent gangrene following the mismanagement of open fractures. By the time he sought formal medical care, the infection had progressed to a point where limb salvage was no longer possible, ultimately requiring hemipelvectomy. This procedure is uncommon in such cases, with a reported incidence of only 2.6% [10]. A 2021 study from Nigeria found that below-knee amputation is the most frequent outcome among patients treated by traditional bone setters [10]. However, in our patient's case, the extent of necrosis necessitated initial hip disarticulation and subsequent hemipelvectomy following further debridement.

Traditional bone setters often employ practices such as scarification and the use of unprocessed herbal remedies, which increase the risk of infection [9]. In this case, the patient's wound became septic and eventually gangrenous, a progression likely caused by the absence of essential medical knowledge in anatomy and fracture management, or the use of nonsterile practices. Improper splinting and excessive manipulation can compromise vascular supply, leading to irreversible tissue damage and limb loss [10]. TBS remains a preventable but significant contributor to major limb amputations across many African nations. Despite its risks, it continues to be a leading cause of gangrenous limb loss on the continent [10].

Conclusion     

Traditional bone setting (TBS) is a preventable cause of major limb loss in many African settings. We present a case of a 17-year-old male who underwent a right hemipelvectomy after mismanagement of an open fracture using TBS. Public education, cultural re-orientation, and government regulation of TBS practices are urgently needed to reduce associated morbidities. Early referral to specialised care centres and public awareness campaigns can significantly reduce preventable complications, improve patient outcomes, and minimise the need for radical surgical interventions like hemipelvectomy.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Jackson Kakooza, William Nsubuga Serwada, Timothy Lwanga and Godfrey Kimbugwe. Data collection: Jackson Kakooza, William Nsubuga Serwada, Timothy Lwanga, Catherine Renee Lewis, and Godfrey Kimbugwe. Manuscript drafting: Jackson Kakooza, William Nsubuga Serwada, Timothy Lwanga and Catherine Renee Lewis. Manuscript revision: Jackson Kakooza, Catherine Renee Lewis, and Godfrey Kimbugwe. All authors have read and approved the final version of the manuscript.

Figures     

Figure 1: preoperative images: A) preoperative photograph of the right lower extremity demonstrating oedema and extensive wounds with associated necrosis; B) extension of wounds to the right iliac fossa with associated purulent drainage

Figure 2: intraoperative photographs: A) intraoperative photograph after right hip disarticulation and extensive debridement; B) initial dressing of the postoperative wound

Figure 3: right hemipelvectomy: A) hemipelvectomy specimen; B) right hemipelvectomy wound

Figure 4: wound closure: A) placement of retention sutures with drain placement; B) further closure of the wound with retention sutures; C) wound after suture removal with areas of closure and healthy granulation tissue

References