Determinants of Traditional Bone Setter (TBS) Preference and Its Association with Delayed Orthopaedic Presentation and Functional Disability Among Rural Trauma Patients at a Tertiary Care Centre

1. Background and Epidemiological Context

• In sub-Saharan Africa, up to 80% of people use traditional medicine as their first port of call after injury.
• A 2025 multicentre study from Northeast Ethiopia found a TBS utilisation prevalence of 55.2% (95% CI: 50.4-60.0%) among patients with orthopaedic injuries.
• A cross-sectional study from Ethiopia (Black Lion Hospital, Addis Ababa) found 29.9% of fracture patients preferring TBS even when admitted to a tertiary hospital.
• In Nigeria (Ilorin), 52.3% of community respondents had patronised TBS at some point, and 69.3% believed TBS to be preferable to orthodox medicine.

2. Determinants of TBS Preference

2.1 Sociodemographic Factors

2.2 Injury-Related Factors

• Extremity trauma (limb fractures/dislocations) is significantly more associated with TBS use (AOR = 1.82, 95% CI: 1.11-2.99) compared to axial/trunk injuries. Communities perceive extremity injuries as less severe and "more manageable" by TBS.
• Hospital admission history: patients previously hospitalised were 8.16x more likely to prefer TBS in subsequent injury episodes (likely driven by negative hospital experiences or fear).

2.3 Cultural, Attitudinal, and Systemic Factors

1. Cultural belief and community trust - TBS are perceived as traditional specialists in bone and joint disease; treatment carries spiritual/ancestral legitimacy
2. Cost - TBS fees are substantially cheaper than hospital admission and surgery (cited by 63.8% in Ilorin study)
3. Geographic accessibility - TBS are located within or near villages; the nearest orthopaedic hospital may be many miles away
4. Quick service - TBS provide immediate, flexible consultation without appointment or queuing
5. Social pressure - Influence from family and friends is the single most cited reason for patronage (53.6% in Ilorin); peer networks actively recommend TBS
6. Fear of amputation - A pervasive belief exists that referral to a teaching hospital equates to amputation (cited by 54.35% in Ilorin)
7. Fear of surgery / metalwork - Fear of implants, screws, or plates inside or outside the limb
8. Perception of efficacy - Patients who perceived TBS as better than health facilities were significantly more likely to use them (converse: not perceiving TBS as better reduced preference by 97.4%; AOR = 0.026)
9. Familiarity with TBS, unfamiliarity with hospital systems - TBS are known by name in the community; hospitals are impersonal and bureaucratic

• Negative attitude of healthcare workers
• Long waiting times in hospital OPD/emergency departments (71.0% in Ilorin)
• Perceived risk of amputation or complicated surgery

3. Association with Delayed Orthopaedic Presentation

3.1 Nature and Magnitude of Delay

• The majority of patients who first attend TBS present to formal orthopaedic services only after complications arise - days to weeks (sometimes months) after the initial injury
• Delays are compounded by the sequential pathway: injury → TBS (primary care) → failed TBS treatment → tertiary hospital (often last resort)
• Studies from Nigeria (NOHE, Enugu) found that 5 of 8 interviewed surgical patients had first sought TBS care, and 2 of those 5 required subsequent amputation

3.2 Why TBS Delay Is Clinically Critical

• Compartment syndrome from tight wrapping
• Bonesetter's gangrene - a recognised clinical entity describing distal limb gangrene from constricting TBS dressings applied over fractures with associated vascular compromise

4. Complications and Functional Disability

4.1 Documented Complications (Evidence from Ogwa, Nigeria - Eze et al., Eur J Radiol 2012, PMID: 21733651)

• 65/90 (72.2%) had fracture or dislocation
• 44 of 65 (67.7%) with fracture/dislocation had complications:
  • Malunion: 70.4% - the most common complication
  • Non-union: 18.2%
  • Secondary osteoarthritis: 18.2%
  • Non-reduction of dislocation: 11.9%
  • Other complications: 27.2%

4.2 Functional Disability Consequences

1. Malunion - Results in limb shortening, angular deformity, rotational malalignment. Causes gait abnormality, joint overload, chronic pain, and reduced working capacity in manual labourers.
2. Non-union - Persistent fracture instability and pain. Often requires complex reconstructive surgery (bone grafting, intramedullary fixation) with prolonged rehabilitation.
3. Bonesetter's gangrene and amputation - Permanent limb loss. Amputees in rural settings have extremely limited access to prosthetics, rehabilitation, or disability support services.
4. Chronic osteomyelitis - Recurrent infection, sinus tracts, pathological fractures, progressive bone destruction. May require multiple debridements and prolonged antibiotic therapy.
5. Joint contractures and stiffness - From immobilisation in non-functional positions, herbal dressings causing chemical burns, and tissue fibrosis.
6. Compartment syndrome sequelae - Volkmann's ischaemic contracture (forearm/hand), foot drop, clawing of digits.
7. Delayed union in elderly - Higher risk of secondary fracture displacement, avascular necrosis (femoral head), and perioperative mortality when surgery is eventually needed.
8. Psychological and socioeconomic disability - Loss of livelihood, dependency, and depression are disproportionately high among rural agricultural workers whose income depends on physical function.

5. Conceptual Framework for a Study at a Tertiary Care Centre

Study Design Options

• Cross-sectional analytical study - most commonly used; pragmatic for resource-limited settings
• Retrospective cohort - compares outcomes in TBS-treated vs. directly presenting patients
• Mixed methods - quantitative prevalence data + qualitative in-depth interviews for preference determinants

Key Variables to Measure

• Sociodemographic: age, sex, residence (rural/urban), education, occupation, income, marital status, ethnicity/tribe, religion, health insurance status
• Injury-related: type of injury (fracture/dislocation), site (upper vs. lower limb, axial), mechanism (RTA, fall, assault), severity
• Attitudinal: knowledge of TBS risks, perception of TBS efficacy, fear of surgery/amputation, social influence
• Systemic: distance to nearest orthopaedic facility, availability of transport, prior healthcare experience

• Delayed presentation (days from injury to first orthopaedic contact; often defined as >48 hours or >7 days depending on study)
• Functional disability - assessed using validated tools:
  • DASH score (Disabilities of Arm, Shoulder and Hand) for upper limb
  • LEFS (Lower Extremity Functional Scale) for lower limb
  • WHODAS 2.0 (WHO Disability Assessment Schedule) for general disability
  • Barthel Index or modified Rankin scale in elderly
• Complications (malunion, non-union, infection, amputation, gangrene)

Statistical Approach

• Bivariate analysis (chi-square, Fisher's exact, t-test)
• Multivariable logistic regression for binary outcomes (TBS preference, disability)
• Adjusted odds ratios with 95% CI
• Confounders: age, sex, injury severity, socioeconomic status

6. Policy and Clinical Implications

1. Health education targeting rural communities - correcting myths about hospital amputation, explaining risks of TBS (gangrene, malunion, non-union)
2. Training and integration models - structured training programmes for TBS in first aid, fracture recognition, safe splinting, and referral thresholds have been trialled in Nigeria and shown promise
3. Community health worker (CHW) networks - deploying CHWs with orthopaedic first-aid training to serve as a bridge between TBS and formal care
4. Reducing structural barriers - addressing healthcare worker attitude, long wait times, and cost as push factors toward TBS
5. Health insurance expansion - insurance coverage is a significant protective factor against TBS utilisation
6. Dedicated TBS liaison clinics - fast-track assessment pathways for TBS-treated patients to minimise tertiary care delay

Key References

1. Aderibigbe SA, Agaja SR, Bamidele JO. "Determinants of utilization of traditional bone setters in Ilorin, north central Nigeria." J Prev Med Hyg. 2013;54(1):35-40. [PMID: 24397004]
2. Eze KC et al. "Complications and co-morbidities in radiographs of patients in traditional bone setters' homes in Ogwa, Edo State, Nigeria." Eur J Radiol. 2012;81(9):2323-8. [PMID: 21733651]
3. Preference of Traditional Bone Setting - PMC6751593 - Cross-sectional study, Black Lion Hospital, Ethiopia. BMC Musculoskeletal Disorders 2019.
4. Frontiers in Rehabilitation Sciences 2025 - Utilization and associated factors of TBS in Northeast Ethiopia.
5. Nwachukwu BU et al. "Traditional bonesetters and contemporary orthopaedic fracture care in a developing nation." Open Orthop J. 2011;5:20-6.
6. Khan I et al. "Traditional bone setters: preference and patronage." Prof Med J. 2015;22(9):1181-5.