A significant number of patients 75(24.8%) who had amputation were initially treated by Traditional Bone Setters. This is a common practice especially among victims of road traffic crash who had either sustained fracture or dislocation. (Table 1). The patronage of these practitioners enjoys the goodwill that cut across educational and social barriers [16]. This large number may not be unconnected to the believe that traditional bone setters intervention heals faster than orthodox interventions besides the prolong wearing of cast that result in atrophy, gangrene and subsequent surgical intervention by way of amputation and loss of lives in some cases [16]. However more disastrous outcome had been recorded in most of these patients [13,14]. Unfortunately, these horrific outcomes are in most cases outside the public glare and only noticed in hospital setting. It was found that failure rate among those that opted out of traditional treatment was up to 65% [12]. The extent of some of these interventions and their outcome have been described as unacceptable [15].

Trauma from road traffic crash constitute the largest number of causes of injury related casualty and disability (Table 1) and affects more males than female gender. Male: female ratio was 2:1. This is corroborated in finding from other parts of the country because they get involve in injury prone activity [10,18,24]. A large number of these patients patronizes traditional born setters immediately after injury and before arrival to major hospitals 74.4% and 31.8% in Port Harcourt, Kano respectively [17,18]. They do this in order to assuage their sense of urgency and panic that puts them in dear need for help at all cost. The sympathizers of the victim are mainly friends and relatives present at the time of injury and who often think alike [17]. A large number are conveyed to bone setters as result of the myth that accidents and diseases have spiritual components and the despondency and helplessness of road traffic accident victims, their rescuers and the panic that ensues makes this group of patients highly vulnerable to the counsel of traditional bone setters. This is also influence by widespread believe across ethnic, religious and social strata that traditional bone setters perform better than the orthodox medical intervention with underlying myth that accidents and diseases have spiritual components [14,19].

Although other conditions such as conge nital anomalies also consult traditional bone setters, the bulk of what present to hospitals were fractures 71(94.7%) (Table 1). Dislocations are also notice [19,20]. The low access to the Health Insurance Scheme and the high cost of modern orthodox orthopedic care that is said to be prohibitive also contributes to this. One cannot however underscore the prevailing economic crunch in the country where majority live below the WHO defined poverty line. The tendency is for the patients to seek the cheapest care affordable to them or pull out of an established treatment scheme when finances become inaccessible [14,23]. They often decline treatment and constitute a significant number signings against medical advice on admission [25].

It is pertinent to note that in spite of the debility cause by diabetes very few of them patronize the traditional bone setters. Despite lack of awareness of measures of foot care among known diabetic patients which is largely due to a lack of education (19) they do not frequently patronize traditional bone setters.  This revealed by our findings as only 3(4%) (Table 1) diabetics were victims of traditional bone setter’s intervention.

Large number of our patients with significant patronage were below thirty years (Table 2). These are dependent age in with decisions are made on their behalf and because most of them don’t earn a living. In fact, they form the bulk of unemployed and most vulnerable group as they cannot fend for themselves. The degree of damage and morbidity is worse among the young too because any attempt to resist the painful splints or protest the effect of tight splints are always rebuffed or scolded by the parent or care giver. The excruciating pains are often to be regarded as part of the treatment. In adults however, they often pull and throw off the tight splint as soon as he/she could not stand the pain and discomfort.

The vulnerability in children was elaborated by Nwadiaro et al in 1999 where it accounted for over 75% amputation in children [13]. In the decade after that we noticed 34 (45.3%). The fact that children are mainly involved portend a growing number of disable youths that could be rendered handicap later in life. This creates burden of rehabilitation and dependency as more of the young and productive age group are affected. The situation may be more pathetic as it also shrinks their employment opportunities [21].  With this alarming number of patients presenting as emergency as consequence of traditional bone setters’ intervention will soon assume a major public health concern. Needless to say, that most of the victims die before presenting to recognized health facility.

We noticed these victims of traditional bone setters were brought in severe morbid life-threatening forms that requires rapid intense intervention. These conditions include wet gangrene, gas gangrene or combination of such, severe anemia, uncontrolled sepsis, tetanus, deranged electrolytes, uncontrolled blood sugar were all features to contend with by the attending physician. Others include compartment syndrome. These critical conditions present in moribund state warranted that amputations were performed as live saving measure. Suffice to mention that recorded mortality were as a result of worsening of this critical condition.

When patients present with life threatening gangrenes of the extremities known factors that determine the site of election and level of amputation no longer hold sway. What becomes important is the nature and amount of healthy skin tissue that can be mobilized directly to be able to construct a healthy stump. The fulminating necrotic tissues now serves as a limiting determinant in the establishment the level of amputation.  In our instance the ability to raise a healthy flap rather than the initial pathology becomes the main determinant of the level of amputation. With this, commonest level of amputation is a high above knee amputation because necrosis from various forms of gangrene renders only little healthy skin is available to fashion a healthy stump whether above knee or below the knees. A plausible intervention critical to survival of the patient was a modified guillotine amputation with or without pre-fashion flap. This rids the impending ascend of gangrene and accounted for multiple interventions in 40(53.3%) patients (Table 4). With this extended proximal levels of amputation, more complex and sophisticated prosthesis will be required. But availability of this necessity is completely absent in our setting.

The effect of these is the development of multiple complications in over 45(60%) of the patients. Most of these complications are those that warranted reoperation and so added prolong hospitalization, cost of treatment and morbidity associated with anesthesia and nosocomial infection.

In conclusion traditional bone setters form the point of first consult among victims of traumatic injuries of the extremities from road traffic crash. Healthy skin flaps are more determinants of anatomical site of election than the primary pathology and levels of amputation more likely more cephalad because they often present with gangrene. More of the young are expose to this practice than the adults mainly because choice of care givers are made on their behalf.  This, if not mitigated will creates a large cache of young amputees with burden rehabilitation to the society. The need for documentation of these horrific practice of traditional bone setter’s intervention practices is highly desirable.

Our limitation lies on the hospital-based study more emphasis was on restoration of lives as the patients were in life threatening conditions. A prospective study would have been plausible