Of the tumors, nine were osteogenic sarcoma, and one was large cell lymphoma. The main infections were acute soft tissue bacterial (five), chronic osteomyelitis (four), fungal (one), and parasitic (one).
Observations of this study reveal that more than 30% of the 290 amputation cases were in persons aged 18 years and younger. This is comparable with the findings in Nigeria of 32.7%.2 More than 75% of the patients were older than 5 years, indicating that the majority of amputees are patients for whom the amputation interferes with growth and school attendance, thus causing future economic impoverishment unless they are successfully rehabilitated.4 Such rehabilitation requires a multidisciplinary approach involving surgeons, prosthetists, physiotherapists, occupational therapists, and social workers. Unfortunately in developing countries such as Kenya, there is relatively less attention given to amputees because of limited manpower. Accordingly, and also because of resource limitations, only approximately 20% of the amputees in Kenya are fitted with prostheses.10
A multisectoral approach involving government, nongovernmental agencies, and community-based organizations in establishment of child rehabilitation centers where amputees can be fitted with prostheses may improve the outlook for the children. In Australia, free limb schemes work well,11 and in Nepal, all children who have amputation at rehabilitation centers for disabled children are fitted with prostheses.1 Such rehabilitated children are able to use prostheses and return to normal activity in school and life in general.8,9 National policy on establishment of rehabilitation centers for physically disabled children constitutes a viable solution.
Trauma was the leading cause of amputation in this study. This is consistent with the reports in Sub-Saharan Africa that injuries caused by RTA, falls, burns, assaults, bites, stings, and other animal-related cases are common and may be on the increase.12 The figure of 42% is higher than 29.54% reported for Nepal1 but lower than 74.3% reported for Nigeria.2 In Malawi, as in Netherlands and Jordan, the most common causes are associated with congenital malformations (Table 3).
It may be difficult to compare the figures because of differences in definitions of children and sample sizes. However, these variations suggest that the cause of amputation among children varies between countries (Table 3). For example, in Nigeria, the majority of traumatic cases are because of gangrene after attempts to fix fractures by traditional bone setters,2,15 whereas in this study, the most common cause of traumatic amputation was burns. The latter is consistent with the reports that, in Kenya, the most prevalent childhood injuries are burns.16 In most cases, amputation is performed in thermal burns with extensive tissue necrosis or on those complicated by infection.17 In this study, burns constitute 11.4% of the total and 27% of traumatic amputations. This high proportion may be related to the custom of placing fires at floor level, which predisposes to burns in children who crawl or play inside or around the hut18 or to the habit of leaving young, inexperienced children to prepare meals for themselves and siblings. Indeed, cooking-related injuries are a common problem worldwide, resulting in more pediatric burns than any other cause.19 In virtually all the cases, the burns were complicated by infection. In these cases, early amputation reduces the mortality rate.20
A total 16.2% (16.2%) of trauma cases and 6.8% of the total cases are because of RTA. This is much lower than the reported figures for adults5,6 and probably reflects low vehicular traffic in rural Kenya. Implementation of stringent road safety regulations will reduce this further. Another remarkable cause of traumatic amputation is animal, especially snake bite at 8% of the total and 18.9% of the traumatic cases. These figures are much higher than 0.8% reported for Nigerian adults4 and 3% of Tanzania and Kenyan adults.6,18 Snake bites are frequent among teenagers in African countries, commonly related to farming and rainy seasons.21,22 Amputation is because of ischemic limb necrosis from snake venom or a tourniquet. The bites involved the hands and feet in young individuals working on the farm or walking barefoot. Enforcement of snake eradication programs by trapping, confinement, or killing and protective footwear may constitute a valuable control measure.
Falls from heights constitute another major cause of amputation in young people as reported in Nigeria.23 In developed countries24 and in urban settings in Africa,25 falls are a leading cause of hand injuries. In a recent Kenyan study, falls were the third most common cause of hand injuries after occupational injury and assault.26 In this study, falls constituted 13.5% of the trauma cases and 5.7% of the total. In Malawi, for example, falls constitute nearly 30% of injuries.27 Among rural communities, these falls generally result when children climb trees to forage for fruits. This implies that ready accessibility to fruits, other food, and guarded home environments will reduce falls.
In rural areas, cuts and stabs, especially those related to agriculture and domestic accidents, constitute a common cause of injury.16,25 In this study, these cuts that constitute 10.8% of trauma cases resulted from kitchen or farm accidents, most likely related to inexperienced use of the implements by children. Reduction of child labor and use of protective footwear on the farm may prevent these amputations. Thorn pricks, fairly common in rural communities, are a risk factor for acute pyogenic and chronic osteomyelitis,28,29 and in this study, they were indeed complicated by bacterial infection. Injury from bomb blast and arrow stabs from political violence caused amputation through vascular injury and infection. Occurrence of these cases in children calls for their protection.
More than 12% of amputations are because of infection. The relatively high rate of bacterial infection (5.7%) suggests late presentation, poor hygiene, and wound care among children, and calls for greater vigilance in the management of sepsis and general health education on environmental hygiene. Several of these are cases of chronic osteomyelitis. These figures are comparable with those reported in a general population.6 Treatment of osteomyelitis by amputation is preserved for cases in which active or recurrent disease is so entrenched that cure with the preservation of a reasonable amount of limb function is not possible, as in cases with nonunion and extensive necrosis of bone, muscles, arteries, and nerves.29 A high index of suspicion for osteomyelitis in children with minor trauma from cuts, pricks, bites, and their rational timely treatment30 will help to reduce amputation. The two cases of parasitic and fungal infection are also consistent with reports from tropical countries.4,18 Control of infection and use of appropriate footwear may be useful preventive measures.
Tumors were responsible for 11.4% of amputations, comparable with the general population figures reported in Kenyan literature.5,6 Osteogenic sarcoma constituted 90% of the tumors. The high proportion of amputations because of osteogenic sarcoma, which is amenable to nonsurgical treatment or limb salvage surgery, has been attributed to late presentation of patients,7 perhaps because of poor accessibility to health care. Congenital malformations, usually the most common cause in most populations (Table 3), constitute the second most common cause of amputation in this study. Their profile and distribution resemble those recently described in a general population6 study and invite the evaluation of congenital defects in rural Kenya.
Children and adolescents constitute more than 30% of amputees, consequent to preventable causes that are related to poor socioeconomic status in a rural tropical environment. Improvement of living standards and establishment of rehabilitation programs for children are recommended.
The authors thank the PCEA Kikuyu and Tenwek Mission Hospital Management Boards for approval to use their registries to access records and Catherine Chinga for typing the manuscript.
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Keywords:© 2010 American Academy of Orthotists & Prosthetists
amputation; children; rural; Africa; Kenya