Risk Factors for Amputation and Prolonged Hospitalization Among Children Who Received Traditional Bonesetting in Ethiopia
Authors: Adem Ephrem G. , Morgan-Asiedu Papa K. , Mengesha Mengistu G. , Keko Mario , Mo Chen , Bussa Sintayehu , Alemu Eden , Zerihun Yishak , Derilo Habtamu T. , Areis Mahamed , Reda Kaleab T. , Workneh Wubshet A. , Shiferaw Bahru A. , Jira Moa C. , Gula Habtamu B. , Geneti Mulugeta B. , Martin Claude , Agarwal-Harding Kiran J. , Harrison William J. 
Published: February 2025

Background:
In Ethiopia, orthopaedic services are limited, and many injured children undergo traditional bonesetting (TBS) despite its association with limb- and life-threatening complications. We sought to identify the risk factors for amputation and a prolonged hospitalization of >7 days in children who presented to hospitals after undergoing TBS.

Methods:
Over a 15-month period, we prospectively enrolled children who presented to 8 Ethiopian hospitals after undergoing TBS. Separately for each outcome (amputation and prolonged hospitalization), we used multivariable logistic regression to evaluate associations between the outcome and 16 covariates, including demographic and injury characteristics, parent or guardian preference for TBS, and TBS topical treatments and immobilization methods.

Results:
We enrolled 460 children (mean age, 9.0 ± 4.0 years; 75% male) representing 8 Ethiopian regions and diverse demographic and socioeconomic backgrounds. Elbow injuries (194 patients; 42.2%) and closed fractures and/or dislocations (364 patients; 79.1%) were most common. TBS treatments included topical inorganic (190 patients; 41.3%) or organic (82 patients; 17.8%) material application and rigid (166 patients; 36.1%) or soft (182 patients; 39.6%) immobilization. Twenty-six children (5.7%) underwent an amputation, and 102 (22.2%) had a prolonged hospitalization. The odds of amputation were higher for children from rural communities (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 2.01 to 22.41) and for children with only non-osseous injuries (AOR, 5.76; 95% CI, 1.56 to 21.28). The odds of prolonged hospitalization were higher for children who were 11 to 17 years old (AOR, 2.77; 95% CI, 1.18 to 6.50) and for children with open fractures with a grade of ≥2 (AOR, 4.52; 95% CI, 1.33 to 15.28) but were lower for children from households with secondary education or higher (AOR, 0.40; 95% CI, 0.21 to 0.79). TBS with rigid immobilization increased the odds of amputation (AOR, 5.84; 95% CI, 1.74 to 19.60) and prolonged hospitalization (AOR, 2.20; 95% CI, 1.02 to 4.73). TBS organic topical treatment (with mud, leaves, or butter) increased the odds of amputation (AOR, 3.88; 95% CI, 1.40 to 10.73).

Conclusions:
For children who underwent TBS prior to hospital presentation, rigid splinting by bonesetters increased the odds of amputation and prolonged hospitalization. TBS organic topical treatments also increased the odds of amputation. Training bonesetters to avoid these dangerous practices may prevent devastating complications for children in Ethiopia.

Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.