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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00996-9
10.1016/j.ijscr.2024.110215
110215
Case Report
Management of dead limb following traditional practices in Indonesia: A case report☆
Winanto I.D. Iman.dwi@usu.ac.id
⁎
Tirta C.
Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Sumatera Utara - Adam Malik General Hospital, Medan, Indonesia
⁎ Corresponding author. Iman.dwi@usu.ac.id
30 8 2024
10 2024
30 8 2024
123 11021512 7 2024
19 8 2024
24 8 2024
© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Traditional bone setting, a centuries-old practice, remains a common method for treating musculoskeletal injuries in many parts of the world, particularly in developing regions. In Indonesia, traditional bone-setters are widely sought after in managing various bone and joint conditions. Despite the widespread use of traditional bone settings, there is limited documentation of their treatment outcomes and potential complications. Complications such as a necrotic limb due to vascular interruption as shown in our case are common complications of fracture reduction by individuals who have not been formally trained.

Case report

This case report presents a 4-year-old boy, who came in the emergency department with pain on the arm after falling from the stairs. After a thorough examination, it was concluded that this patient has a displaced right proximal humerus fracture. The patient and family are educated about the surgery to treat the patient, but they refuse to do so. Two days later, the patient was referred to our hospital with a complaint of a blackened upper arm after undergoing a traditional bone-setting procedure. The patient's condition was characterized by loss of motor and sensory function in the affected limb, which was confirmed through clinical examination and imaging studies. He underwent shoulder disarticulation by an orthopedic surgeon in our center. This was decided because the limb was non-functional, inconvenient, and is at risk of becoming a focus of infection.

Discussion

Dead limb caused by traditional bone setters is a major factor leading to amputations in numerous developing nations. Techniques such as scarification, massage with herbal preparations, and the application of tightly fitting splints can result in infections, vascular impairment, and compartment syndrome, ultimately culminating in gangrene or limb loss. This case highlights the progressive and potentially limb-threatening nature of such infections, underscoring the critical need for early identification of compartment syndrome, prompt resuscitation or stabilization efforts, and immediate, vigorous treatment.

Conclusion

This case is reported to highlight the risks associated with traditional bone-setting practices and the inherent dangers they pose. Individuals misled by misconceptions should be educated through public awareness campaigns. Additionally, governmental legislation should be enacted to integrate traditional bone-setting practices with modern orthopedic care services.

Highlights

• Bonesetters are still popular in the developing country.

• Bonesetters lacks basic comprehension of anatomy, physiology, and biomechanics.

• Bonesettings are associated with high morbidity and mortality rate in the developing country

• Proper education on the dangers posed by bonesetters is an important point to note in practice.

Keywords

Compartment syndrome
Dead limb
Traditional bone setting
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pmc1 Introduction

Traditional bone setting, a centuries-old practice, remains a common method for treating musculoskeletal injuries in many parts of the world, particularly in developing regions. In Indonesia, traditional bonesetters are widely sought after in managing various bone and joint conditions. Despite the widespread use of traditional bone settings, there is limited documentation of their treatment outcomes and potential complications [1]. Traditional bone setting has deep roots in North Sumatera Province, predating the advent of modern medicine, which has contributed to its enduring popularity among the community. A significant portion, amounting to 72.8 %, opted for traditional bone setting as their preferred treatment, with an additional 28.4 % utilizing homemade remedies [2]. Despite its inherent limitations, several patient-related factors continue to drive demand for traditional practices. These include factors such as lack of awareness, influence from peers and family, low socioeconomic status, reluctance towards surgical implants, fear of amputation, adherence to cultural beliefs, and trust in traditional remedies and rituals [3].

A dead limb is a clinical finding of a non-viable tissue, characterized by pain, cold extremity,discoloration of the affected extremity and the lack of functional neurovascular structures which will manifest as a sensory and motoric function disturbance along with lack of distal pulse. Diagnostic results shows increase in WBC The epidemiology of upper limb amputation due to traditional bone setting is not explicitly mentioned in the provided sources. However, it is mentioned that traditional bone setting is a significant contributor to amputations in many developing countries, particularly in Ethiopia and other low- and middle-income countries. The practice of traditional bone setting often lacks the fundamental scientific principles of fracture management and infection prevention and control, leading to complications such as non-union, malunion, chronic osteomyelitis, limb gangrene, compartment syndrome, and joint stiffness, which can sometimes result in amputation. Sume and Geneti found that traditional bone setting was a major determinant cause of limb amputations in Ethiopia, with 24.10 % of amputations attributed to traditional bone setters [4]. In study of Salihu et al. in Nigeria, 297 major limb amputations were performed, 194 (65.3 %) were due to traditional bone setting and traditional bone setting is a leading cause of major limb loss especially in children [5].

Traditional bone setting practices without regulation and lacks the foundational scientific principles of managing fractures and controlling infections. This method primarily relies on herbal and earth-based mixtures applied to limbs, which are then inadequately immobilized with wooden splints, without incorporating knowledge from anatomy, physiology, or radiology [3]. Furthermore, it underscores the need for healthcare providers to be aware of the potential complications that can arise from these treatments and to develop strategies for managing such cases effectively [6]. This case report aims to contribute to the existing literature on traditional bone setting practices and to provide valuable insights for healthcare professionals working in similar settings.

2 Case report

A 4-year-old male child came to our emergency department with pain on the right arm after falling from the stairs with unspecified mechanism one day before admission. The patient was alert with normal vital signs on presentation. Deformity, angulation, swelling, and bruise were not seen on the initial visit. The arm was held in a fully extended position. Palpation of the upper limb showed tenderness, and crepitation at the level of proximal humerus. Normal pulse was palpated at the radial artery and no sensory disturbances were noted. The capillary refill and oxygen saturation for each finger was around 95–98 %. Range of motion (ROM) examination showed there was no active movement from the right shoulder joint and elbow due to pain with normal ROM in the wrist joint and all digits. Laboratory result at the time of admission showed: hemoglobin 10.1 g/dl, hematocrit 30.1 %, erythrocyte 4.02 × 106/mm3, white blood cells 29.170/μL. The patient then underwent X-ray imaging and was found to have a displaced right proximal humerus fracture. The medical team recommended surgical intervention upon diagnosing a closed fracture; however, the patient elected to be discharged against medical advice, opting instead for treatment by a traditional bone setter. The clinical appearance and X-ray imaging of the patient is shown on Figs. 1 and 2.Fig. 1 Clinical appearance of the patient 1 day after the fall.

Fig. 1

Fig. 2 Anteroposterior (AP) and lateral (L) X-ray view of the right upper extremity.

Fig. 2

One day after the patient was discharged against medical advice and underwent traditional bone setter's treatment, he came back to our emergency department with a blackened right upper limb since the arm was manipulated by a bonesetter immediately after he was discharged against medical advice the day before, as shown in Fig. 3. The bonesetter manually manipulates and massages the arm without administering analgesics, while an unknown herbal cream was topically applied to the upper arm. Subsequently, a bandage was applied directly over the cream, without the use of a splint. Physical examination at presentation showed he was alert with tachycardia (110 beats/min), a slight fever (37,9 °C), and a painful arm. The right upper arm was blackened with a couple of bullae. Deformity, angulation, swelling, or bruises were not seen in this case. The arm was held in a fully extended position. No pulse was palpated at the radial artery and ulnar artery with loss of sensory function in the innervation of the radial, median, and ulnar nerve. The oxygen saturation of each finger can no longer be measured. No history of fever or loss of consciousness. There was no history of medication use besides herbal treatment. A diagnosis of dead limb secondary to bone setter's treatment was made. The patient and his family were informed about the urgent need for amputation after stabilizing the patient's condition, the family were initially reluctant on the decision of amputation and the patient was again discharged against medical advice to consult their bonesetter. He was given NaCl 0.9 % intravenous fluid, antibiotics (ampicillin, 1 g every 6 h; gentamycin 114 mg every 24 h), and analgesics (fentanyl, 200 μg in 50 cc normal saline 2.3 cm3/h). They came again the next day with worsening condition, and the decision to amputate was made by the family. The timeline of clinical appearance is shown on Fig. 3. He underwent shoulder disarticulation with open stump by an orthopedic surgeon in our center on Fig. 4. And after 2 weeks after the inflammatory phase was done the stump was closed. This was considered because the limb was non-functional, wound care was inconvenient, and the non-functional limb was a risk for a source of infection.Fig. 3 Timeline of clinical appearance of the limb prior to bone setter's treatment - 1 day after injury (a) and after the bone setter's treatment - 2 days after injury (b) and 3 days after injury (c).

Fig. 3

Fig. 4 Preoperative (left) and postoperative (right) appearance of the limb.

Fig. 4

3 Discussion

Most of the complications arising from traditional bone setting practices, as outlined in the reviewed studies, primarily affect the musculoskeletal system. These include issues such as malunion, non-union, limb gangrene, amputations, and compartment syndrome. Some reported complications extend to systemic infections and nervous system impairments [7]. These adverse outcomes are often attributed to the unscientific nature of the treatment methods, a point underscored by several studies [8,9]. In cases where local splints were applied too tightly by traditional bonesetting to immobilize limb fractures, severe complications such as compartment syndrome, Volkmann's ischemic contracture, and gangrene occurred. The ramifications of these complications are significant both for health and socioeconomic reasons, particularly affecting young adults in their reproductive years. Such complications also present substantial challenges for orthopedic surgeons, often resulting in poor fracture treatment outcomes [7,10].

Three main aspects of traditional bone setting practice contribute significantly to the complications observed. Firstly, inadequate reduction and immobilization of fractures are associated with issues such as malunion and non-union. Secondly, the use of tightly applied local splints has been linked to the development of severe conditions like compartment syndrome, Volkmann's ischemic contracture, and limb gangrene. Thirdly, complications such as toxemia, chronic osteomyelitis, and cellulitis often stem from poor patient selection and inadequate infection control measures [11]. The primary reason for seeking traditional bone setting services in this study was influenced by advice from family and relatives. The significant influence of relatives is underscored by the social structure in Indonesia, where family and friends typically play a crucial role in treatment decisions. Similar findings were observed in a study conducted in Cameroon, where the advice of relatives and friends accounted for approximately 30.6 % of traditional bone setting patronage. Other factors contributing to the choice of traditional bone setting included lower costs (24.5 %), sociocultural beliefs (14.3 %), ease of accessibility (12.4 %), fear of amputation (10.2 %), and fear of surgery (8.2 %) [12]. However, another study by Dada et al. highlighted that perceived affordability (27.9 %) emerged as the primary reason for choosing traditional bone setting, followed closely by familial and peer pressure (25 %). Although in some instances economic burden can be the driving factor that drove patient into getting treatment at a bonesetter rather than from a medical professional, but our case depicts a case of patient going into bonesetter even though the national insurance will fully cover the cost of legitimate orthopedic services. [13]

This case demonstrated the presence of the dead limb with suggestive of pre-existing compartment syndrome characterized by the history of intense pain, which is usually out of proportion to the degree of injury after the elastic bandage are applied. Unfortunately, the pain was unrecognizable, as it was taken as a normal response to the injury. The tightness of the elastic bandage that spanned through the entire upper arm created a tourniquet effect leading to compartment syndrome, vascular compromise, ischemia due to increased intra-compartmental volume [14].

The primary goal of the treatment was to prevent further ascending infection and toxemia, which was achieved by amputation. The ischemic part is already extended to whole upper right limb. Prosthetic fitting may compensate for the loss of body structures and functions of the affected limbs [3,15]. However, a prosthetic limb could not be designed as there is a lack of prosthetic services in Indonesia.

In presenting this neglected case, the authors suggest highlighting a progressive, potentially limb-threatening infection to underscore the importance of early identification of compartment syndrome, adequate resuscitation or stabilization, and immediate, aggressive treatment. Concurrently, preventive measures should be promoted through public education to raise awareness about the harmful effects of traditional bone setting practices. A critical factor contributing to the disease progression is the lack of awareness among traditional bone setters, who often fail to identify early signs related to tightly applied elastic bandages or splints. Therefore, it is essential to implement comprehensive training programs for traditional bone setters that incorporate basic principles of orthopedic care [16].

To effectively reduce these health risks, it is crucial for the government to contemplate subsidizing hospital expenses and broadening the coverage of National Health Insurance to encompass fracture treatment procedures. These actions represent crucial measures aimed at decreasing the morbidity and mortality linked to traditional bone-setting practices in the coming years but because our article is a case report which only consist of a single case, it might not be sufficient to make any significant wave of change in the governing regulation of such practices. The case report has been reported in accordance with the SCARE criteria [17].

4 Conclusion

Compartment syndrome represents a complication arising from traditional bone setting practices, sometimes necessitating amputation as a life-saving measure. The resulting loss of a limb imposes lifelong disability, significantly impacting both the patient and their family. Despite these complications, the public maintains a strong belief in the abilities of traditional bone setters. Therefore, this case is reported to underscore the risks associated with traditional bone setting practices and the inherent dangers they pose, where future reports of similar cases might prove to be sufficient for a more drastic measures against uncontrolled alternative therapy to be called by the government. Individuals misled by misconceptions should be educated through public awareness campaigns. Additionally, governmental legislation should be enacted to integrate traditional bone setting practices with modern orthopedic care services.

Informed consent

Informed consent regarding the case series were informed to the patient at the last follow up and written consent is available whenever the editor or reviewer asked for it.

Ethical approval

This study is an observational case report without any difference in intervention for the patient, and so the study is exempted from ethical approval by the ethical committee of our institution “Komisi Etik Universitas Sumatera Utara”.

Funding

There is no external funding source for this case series.

Author contribution

Dr. Iman Dwi Winanto, Sp.OT (K)- Study concept

- Data analysis

- Writing the paper

Dr. Clement Tirta- Data collection

- Data Analysis

- Writing the paper

- Study concept

Guarantor

Dr. Iman Dwi Winanto, Sp.OT (K).

Dr. Clement Tirta.

Research registration number

The study is not a “first in man” study.

Conflict of interest statement

All authors declare that there is no conflict of interest associated with this case report.

☆ Provenance and peer review and not commissioned, externally peer reviewed.
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