Traditional Bonesetters: Risks, Complications, and the Way Forward

Traditional bonesetters have been, and continue to be, used throughout the world for health care, especially in low and middle-income countries1. Traditional bonesetters typically have no formal medical or surgical training in the care and management of orthopaedic injuries, which can include not only soft-tissue injuries, such as abrasions and cuts, but also fractures and fracture-dislocations, both closed and open2. The reasons for patients to go to traditional bonesetters can include patient preference; an inability to access formal medical care, either geographically or financially; and other culturally derived preferences and beliefs3,4. Traditional bonesetting, however, has been associated with potentially higher complication rates compared with formal medically established care1,5,6. This can be especially true when treating orthopaedic injuries. Indeed, recent systematic reviews suggest that these complications can result in malunions, nonunions, and amputations1. The complication of “bonesetter’s gangrene” has been documented in the literature and is associated with the use of overtight splinting techniques that can restrict blood flow and cause ischemia and subsequent necrosis in the limb5,7. Such cases require further surgical intervention, most commonly an amputation of the necrotic limb. Even though this potential increased risk of complications exists, many patients still look to use the services of traditional bonesetters8. This has led some in the medical community to suggest increasing collaboration with bonesetters and furthering their education in order to help mitigate complications6,9. The study by Adem et al., “Risk Factors for Amputation and Prolonged Hospitalization Among Children Who Received Traditional Bonesetting in Ethiopia,” highlights just such complications. This study is an important addition to the literature, as it was a large and robust trial performed in collaboration with multiple hospitals and centers throughout Ethiopia as well as Harvard Medical School, the University of Pennsylvania, and the AO Alliance Foundation. The study enrolled 460 children who had arrived for pediatric orthopaedic care at 1 of the 8 Ethiopian hospitals involved in the trial. These children had previously seen traditional bonesetters prior to their arrival. This study demonstrated that the odds of amputation were higher for children from rural communities and, interestingly, for children with only non-osseous injuries. The odds of prolonged hospitalization were higher for children between the ages of 11 and 17 years and for those with open fractures of grade ≥2. The odds of prolonged hospitalization were lower for children from households with a secondary education or higher. The authors identified that rigid immobilization by traditional bonesetters increased the odds of both amputation and prolonged hospitalization and that the use of organic topical treatment by traditional bonesetters increased the odds of amputation. Given these serious complications and increases in hospital use, it is difficult to know what to do as a general collective of globally minded orthopaedic surgeons. The 2 options that are available are (1) avoiding and discouraging the use of traditional bonesetting completely or (2) educating traditional bonesetters in the appropriate management of orthopaedic injuries. Given the current health-care climate in many places of the world, and specifically in lower and middle-income countries, avoiding the use of traditional bonesetters may not be feasible2,8. Indeed, as mentioned, and as I have seen through my own experiences and those of my friends and colleagues, there are several reasons that patients will continue to seek the care of traditional bonesetters. As a global community, we must strive to continue to push health care—especially timely and financially available access to orthopaedic care—as an inalienable human right. It may be that education, both within the patient community as a whole and within the traditional bonesetting community, would be a feasible way forward7,10. The study by Adem et al. highlights both an important aspect of prehospital care and the need for continued education. Further, this study helps us to identify important target populations for collaborative educational interventions and initiatives.

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