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212 Musculoskeletal Trauma

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the reasons patients sought alternative care. Clearly, more specialists for soft tissue infections and microvascular tissue transfer for massive
must be trained to manage these injuries, which will eliminate the open wounds. However, these are extremely expensive procedures
menace of traditional bonesetters in the long run. that require prolonged hospitalisations and frequent return trips to
Perhaps it is possible that African paediatric surgeons could specialists. Due to the limitations in resources and transportation in
negotiate some form of peaceful coexistence with traditional healers, so Africa, it is possible that an early amputation will result in more rapid
that their methods, which are highly regarded in some communities, are healing of wounds, less burden on the family, and a more rapid return
supplemented by modern biomedical science to prevent catastrophes; to a stable home life. Limb loss may have consequences, however,
this form of relationship has been successful with traditional birth when the child becomes an adult with a disability. Thus, the decision to
attendants in reducing maternal mortality rates in Nigeria. amputate an extremity will weigh heavily on a surgeon.
Ethical Issues Evidence-Based Research
In the setting of major soft tissue infections, open wounds, or Table 32.1 presents a retrospective case series involving nonoperative
complex open fractures in African children, the decision to perform an management of paediatric type I open fractures of the tibia. Table 32.2
amputation can be extremely difficult. Western countries have countless presents a retrospective case series involving bonesetter’s gangrene.
approaches to these complex injuries, including hyperbaric oxygen
Table 32.2: Evidence-based research.
Table 32.1: Evidence-based research.
Title Bone setter’s gangrene
Title Nonoperative management of pediatric type I open fractures Authors Bickler SW, Sanno-Duanda B
Authors Iobst CA, Tidwell MA, King WF Institution Department of Surgery, Royal Victoria Hospital, Banjul,
Institution Miami Children’s Hospital, Miami, Florida, USA The Gambia; Division of Pediatric Surgery, Department of
Surgery, University of California, San Diego Medical Center,
Reference J Pediatr Orthop 2005; 25(4):513–517 San Diego, California, USA
Problem Open tibial fractures. Reference J Pediatr Surgery 2000; 35(10):1431–1433
Intervention Nonoperative management of type I open fractures using Problem Bonesetter’s gangrene.
antibiotics, wound cleansing, sterile dressings, and fracture
immobilisation. Comparison/ Retrospective case series, no controls.
control (quality
Comparison/ Retrospective case series, no controls.
control (quality of evidence)
of evidence) Outcome/effect Nine children were treated for bonesetter’s gangrene during
a 29- month period, accounting for 0.5% of all paediatric
Outcome/effect There was only 1 deep infection out of 40 patients treated surgical admissions. The average age of children with
with the nonoperative management protocol (2.5%). bonesetter’s gangrene was 8.2 years (range, 5 to 14 years).
There were 6 boys and 3 girls (male to female ratio, 2:1).
Historical The techniques described in this paper could be easily The left upper extremity was most commonly involved (n =
significance/ adapted to the care of open fractures in children in Africa. 54), followed by the right upper (n = 53) and left lower (n =
51). Eight of 9 children (89%) were from rural areas in which
comments
access to health care was limited.
Historical Bonesetter’s gangrene is a major public health problem for
significance/ children in Africa.
comments

Key Summary Points

1. Fractures are common among children in Africa. 5. Deep wounds into the muscle, even in the absence of fractures,
require inspection, foreign body removal, and cleansing to
2. Traditional bonesetters commonly treat fractures in rural areas.
This treatment may result in nonunion, ischaemic contracture, prevent infection.
gangrene of the effected extremity, and even death. 6. It is important to remember the “life over limb” philosophy when
Encouraging parents to seek professional orthopaedic care for a child with a mangled extremity is encountered. Resuscitation
their children should be a major public health priority in Africa. is the first priority. The principles of orthopaedic damage control
3. Nonoperative fracture reduction with immobilisation is the should be followed. It is possible that an amputation will be
mainstay of fracture management for rural African children. necessary to save the child’s life.
The majority of extremity fractures will have good results with 7. There is almost no literature on child abuse in Africa. However,
these techniques, and most children will return to full function. it is a major cause of injury and death in the United States,
4. Simple (type I) open fractures can be treated with antibiotics, suggesting that these cases likely also occur in Africa.
local wound cleansing, sterile dressings, and fracture
immobilisation.