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TRADITIONAL BONE SETTING: ORIGIN AND

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 International Journal of Therapeutic Applications, Volume 11, 2013, 19-23

International Journal of Therapeutic Applications

ISSN 2320-138X

TRADITIONAL BONE SETTING: ORIGIN AND PRACTICE

*Paramvir Singh , 1Pankaj preet Singh, 2Supreet Bindra
1
* Department of Sports Sciences, Punjabi University, Patiala
2
Physiotherapist, ESIC Model Hospital, Ludhiana

advanced cultures, the best trained healer for

ABSTRACT
A Traditional Bone Setter (TBS) is a traditional
practitioner of joint manipulation, who educate
themselves from tradition and takes up the
practice of healing without having had any formal
training in accepted medical procedures. Bone
setting practice is common in large parts of rural
populations and contributes largely to the
alternative medicine, especially in context of Asia,
Africa and South America owing to deficient health
care services in these developing nations. TBS are
easily accessible, cheaper and believed to give
quick results. At the same time non union,
malunion, traumatic osteomyelitis and limb
gangrene are some of the major complications of
Traditional Bone setting treatment. Despite these
complications, there is a great demand for TBS.
Some patients elect to leave orthodox hospitals in
favour of treatment by a TBS. If properly trained
about the radiological diagnosis, duration of
healing, complications of mismanagement and
rehabilitation exercises, the TBS can be of
immense help in sharing the burden of health
service providers in the developing countries
Key Words: TBS, Joint manipulation, Malunion,
Alternative medicine, Rural population
The traditional bone setters were practicing long
before the orthopedics was introduced to the
1
developing world . Even before the Caveman Grogg
picked up a club and began to hunt, humans have
suffered from fractures. With the increase in the
awareness of injuries and its subsequent treatment,
certain people accepted the responsibility of keeping
and using that knowledge to heal. In tribal cultures
that person was termed as a bone setter whereas in
2
fracture is the orthopedic surgeon .
There is a large difference in the health care
services in the developed and the developing
countries. According to the human development
index: a composite statistic of life expectancy,
education and income indices used to rank countries
into four tiers of human development, India has
been categorized as a country with medium human
3
development .The well organized services in the
developed countries lead to early diagnosis and
treatment. The population of many of these
countries is relatively small, the lesser number of
patients and high doctor patient ratio ensure a
good treatment for everyone. In addition the
effective insurance system in these countries does
not refrain its citizens from the benefits of the
4
specialized treatment . On the other hand the
scenario is not the same for the developing countries
in the continents of Asia, South America and Africa.
Though India occupies only 2.4% of the worlds
land area, it supports over 16% of the worlds
population. There is wide contrast within health
facilities available in the country. At one end there
are well equipped corporate hospitals in
metropolitan cities, performing the state of the art
surgeries, on the other end often there is complete
absence of orthopedic care facilities at the village,
taluka and tehsil level. While there are orthopedic
surgeons in government run district hospitals, in the
context of the lack of infrastructure, their role as
specialists remains limited. Thus both public and
private formal health care sectors fail to cater to the
basic orthopedic care needs and hence a rural
patient has no option, but to approach a bone
5
setter .The accurate statistics about the TBS are not
available for majority of the countries. In a
developing country like India, the TBS are one of the
largest specialist groups practicing traditional
medicines and numbers are superseded only by

19
 International Journal of Therapeutic Applications, Volume 11, 2013, 19-23
traditional birth attendants or Dais. It is believed
that there are about 70,000 traditional healers and
bonesetters in India and that they treat 60% of the
6
entire trauma . Classes of these traditional healers
include traditional birth attendants, traditional
medicine men and the traditional bone setters, the
bone setting practice being the most specialized
7
form of traditional medicine .
Origin of Bone setting
A Traditional Bone Setter (TBS) is a practitioner
of joint manipulation. The TBS can also be defined as
the practitioner whoeducates themselves from
tradition and takes up the practice of healing
without having any formal education or training in
the accepted medical procedures. The functions of
TBS mainly include management of fractures,
dislocations, congenital anomalies along with their
associated complications. The practice of bone
setting is ancestral in nature and is passed on to the
generations, though there is no documentation of
the procedures. Some outsiders also receive their
training via apprenticeship. According to an
estimate, 10 40% of the patients with fractures and
dislocations in the world are managed by the
8, 9.
unorthodox practitioners
Bone setting practices have its roots in most
countries and may vary by name, art and place. As
early as 1900 BCE in Babylon, King Hammurabi
organized a code of laws to regulate medical practice
and set penalties for failure. That code mentions
specifically the Gallabu bonesetters who handled
10
minor surgery, dentistry and slave branding . The
first known written instructions for surgery and bone
setting date to 1600 BCE. The Edwin Smith Papyrus,
an American Egyptologist, described the appropriate
treatment of fractures. By the fifth century ACE, the
writings of Sustra in India offered instructions for
limb amputation and concept of creating iron
prosthetics. Hippocrates also wrote a treatise on
fractures and dislocations known for its accuracy of
anatomy and physiology, which addressed
compound fractures, reduction, dressing and
immobilization. After the descend of the Roman
Empire, advances in medicine slowed. The Roman
Catholic Church became the governing body for the
social and religious activity. Church leaders believed
that sickness was a penalty for sin and called for
prayer and fasting. The priests servants, the
barbers, were the only ones permitted to perform
surgical operations. Because of day to day
interaction with the people, barbers had an
20
th
opportunity to perfect their techniques. By the 15
century, a barbers guild had formed in England to
help, recruit, train and regulate its members and
competed with the surgeons guild to treat the same
th
ailments. The 17 century witnessed a better
understanding of anatomy, the discovery of
circulation of blood, and a new technique for
amputation using a flap. Nicholas Andre published
the first textbook on preventing and correcting
musculoskeletal deformities in children. Thereafter
Hunters research on tendon healing, discovery of X-
rays by Roentgen and many others paved the path
for transition from bone setting to todays
10
orthopedic surgeon .
TBS basic treatment includes bandaging
techniques, management of inflammation, sprains,
strains, dislocations, methods of early healing of
fractures and strengthening of bones using medicinal
products such as oils. The tribes of South Australia
made splints from clay, and the Shoshone Indians
soaked strips of fresh rawhide in water and wrapped
them around limbs. Rawhide and clay hardened
10
when it dried protecting the injured bone .
Strengths and Weaknesses of Bone setting
Bone setting practice involves a remarkable
degree of expertise and skill as it does not involve
11
radiological aids . As this practice is passed on to
the generations, TBS are extremely cautious about
reputation and deliver the best treatment to the
patients. The faith of people in bone setting cannot
be ignored and the fame enjoyed by bone setters is
so much that patients took voluntary discharge from
7
orthodox hospitals to receive treatment from TBS .
At the same time complications of TBS practice
account for 50-60% of the limb gangrene in Nigeria,
necessitating amputations in hospitals and thus
warrants further study in other developing nations
12
as well .
13
Thanni studied factors influencing patronage of
traditional bonesetters and continuing popularity
and concluded that the educational level of the
respondents did not seem to influence the
patronage of and believe in bonesetters. The TBS are
cheaper and utilize faster healing methods. The fear
of heavy plaster of paris bandages, prolonged
periods of immobilization and amputation
influenced people to visit the TBS. In some cases,
apathetic attitudes of orthodox hospitals or coaxing
by relatives, neighbors and TBS canvassers led clients
to TBS. In addition the TBS were viewed as
specialists for minor fractures , easily accessible ,
 International Journal of Therapeutic Applications, Volume 11, 2013, 19-23
reassuring and also offering home treatment and
thus the TBS enjoy strong regional influence and
popularity.
In the study on role of traditional bone setter in
12
primary fracture care in Nigeria, Onuminya found
that TBS services are well preserved as family
practice and training is by apprenticeship, records
are kept by oral tradition, there is no prescribed fee
and patronage for TBS is high. The fracture diagnosis
is based on assessment and experience. The TBS
relies solely on the conservative method and all
fractures are reduced by closed method and
stabilized with an external traditional splint and a
protracted period of immobilization. The outcome of
TBS is good for close fractures of shaft of humerus,
ulna, radius and tibia, but poor for periarticular and
open fractures. Nonunion, malunion, traumatic
osteomyelitis and limb gangrene were the common
major complications of TBS treatment.
14
Ogunlusi et al in a prospective study on why
patients patronize TBS, included twenty nine
patients who presented at orthopedic outpatient
clinic after attending TBS centers. The study revealed
that the males accounted for large portion of the
patients seeking TBS treatment. Duration of
management at the TBS centre was as long as 18
months in a patient with closed femoral shaft
fracture who ended up with a nonunion after
prolonged treatment. Total 79.3% of the patients
went to the TBS center from the sites of injury,
including patients with multiple fractures. Fractures
and dislocations were managed by using the typical
splint made of bamboo, rattan cane and palm leaf
axis knitted together to form a mat which was
wrapped around the fracture site tightly along with
the herbal concoction without consideration for
reduction and alignment. The study also revealed
that 72.4% of the patients attended TBS as they
wanted cheaper and quicker services than the
modern orthopedic treatment. The study also
showed that many of the patients wanted quicker
services for their acute problems and to return to
work early, unfortunately they ended up with the
primary pathologies poorly treated and complicated
despite long period of management. Fear of
amputation was the reason of patronage in 7% of
patients .The complications of the TBS treatment
were nonunion and malunion which accounted for
96.5%. As the complication rate of TBS was very
high, the author concluded that affordable and
accessible hospital services should be provided to
reduce the TBS patronage.
21
The literature does witness some studies with
either equal or far better results of TBS than
orthodox practice.The universally accepted
treatment for forearm fractures today is open
15
reduction and internal fixation.Shang et al tried the
Chinese method of bone separator pads and splint
immobilization in 2,221 forearm fractures and found
that the method is not only simple, economical and
effective but also eliminated delayed union and
16
malunion. Fang et al used paper roll spreaders and
wooden splints in 147 patients with forearm
fractures. They concluded that by preserving
interosseus membrane, manipulative reduction is
greatly simplified and that the wooden splints were
found to be much more effective and satisfactory
than the plaster of paris for immobilization of
fractures of shafts of both forearm bones.The
randomized trials in buckle fracture of the distal
radius have shown that they can be treated
17
effectively in soft bandage .In addition the modern
practice of functional cast bracing, advocated by
18
Sarmiento and Latta bears close resemblance to
some of the bamboo bandaging pattern of the
traditional bone healers.
19
Hemmia et al in the study on long term
effectiveness of bone setting, light exercise therapy
and physiotherapy for prolonged back pain
concluded that traditional bone setting seemed
more effective than exercise or physiotherapy on
back pain and disability, even one year after therapy.
On the contrary, many failures of bone setting
procedures have been reported, leading to a bad
reputation of the providers. Bonesetters have been
widely criticized for their use of irrational methods.
20
Oginni calculated a high failure rate of 66.7%
among patients who voluntarily opted out of TBS
treatment. The traditional bandaging method of
applying splints directly to the skin has often being
mocked more than the traditional tourniquet
fracture splint. The commonly reported
complications include gangrene of the affected limb,
nonunion, malunion, contractures, osteomyelitis and
limb shortening.
21
Chowdhury et al in their prospective study to
analyze complications of fracture treatment by TBS
and factors predisposing to complications in
Dinajpur district concluded that out of 120 patients,
16.7% had a fracture union in acceptable position
with near to normal range of movement at different
joints whereas 83.8% had complications in the form
of malunion (77%), delayed union (6.8%), nonunion
 International Journal of Therapeutic Applications, Volume 11, 2013, 19-23

(13.5%), gangrene (1.5%), compartment syndrome health care system with special reference to
(2.7%), extensive blister formation and cellulites orthopedic practice and malpractices in India. The
(20.3%), Volkmanns ischemic contracture (3.4%) literature has depicted that even though the medical
and rest had stiffness of elbow and shoulder. facilities have been provided to the populations but
22 in remote areas the approach of health care system
Hag and Hag in their study on complications of
was not found to be satisfactory. The scarcity of
fractures treated by traditional bone setters in
availability of medical care in remote area has
Khartoum, Sudan reported compartment syndrome
helped local non-qualified practitioners named as
(14.3%), osteomyelitis (8.6%), and restriction of
TBS to promote their approach among the
movement (11.4%), Volkmanns contracture (5.7%)
population. Eighty percent of the total population in
and gangrene (8.6%) which ended in amputation to
India reside in rural areas where TBS have performed
be the complications of bone setting. Besides these
there services for the welfare of the society. The non
complications, there is a great demand for TBS
reliable doctor patient ratio in rural population has
services, so much that some patients elect to leave
lead to the promotion of the TBS services and
orthodox hospitals in favour of treatment by a TBS.
healing related complication have arisen with
The possible reasons for this include cultural beliefs,
greater pace but up to date data is not available. The
ignorance, and third party advice, short supply of
complications of TBS treatment namely gangrene,
trained orthodox man power in rural areas, quicker
mal-union, non-union have been produced due to
and cheaper services and the fear of amputation at
14 lack of proper training and non documenting
an orthodox hospital . The rehabilitation is seldom a
approach in spite of that the faith of patients in TBS
part of TBS services. Since not all the patients
cant be ignored and if adequate training along with
treated by TBS report back to the orthodox
certification courses is devised for the TBS, they can
hospitals, except those with complications, it is
be of great help in primary health care thus reducing
believed that there must be many patients with
the load on the health care systems of the
minimally displaced fractures who have been
23 developing nations.
successfully treated by them .
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