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Pattern of Limb Amputation Among Rural Kenyan Children and Adolescents

Ogeng'o, Julius A. BSc, MBChB, PhD; Obimbo, Moses M. MBChB, MSc; King'ori, John MBChB, MMeD Ortho; Njogu, Sarah Wandia MBChB

JPO Journal of Prosthetics and Orthotics: July 2010 - Volume 22 - Issue 3 - p 157-161
doi: 10.1097/JPO.0b013e3181e94834
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The causes of limb amputation among children differ between and within countries. These data are valuable in prevention and planning of rehabilitation strategies for the victims but are scarcely reported. The aim of this study was to investigate the causes of amputation in children and adolescents in rural Kenya. Records of patients aged 18 years and younger who underwent major limb amputation in PCEA Kikuyu and Tenwek Hospitals between January 1998 and December 2008 were analyzed retrospectively for cause and age. Data were analyzed by SPSS (version 11.50). Only complete records for age and confirmed diagnosis were included. Eighty-eight of 290 (30.3%) amputation cases were in individuals aged 2 weeks to 18 years. Trauma was the most common cause (42%), followed by congenital defects (29.5%), infection (12.5%), and tumors (11.4%). Of the trauma cases, burns were the most common cause (27%), followed by animal bites (18.9%), road traffic accidents (16.2%), and falls (13.5%). A total of 77.2% of the patients presented after the age of 5 years. The male:female ratio was 2:1. These data imply that more than 70% of amputations among rural Kenyan children result from preventable causes that may be related to poor socioeconomic status. Improvement of living standards, formulation of public health education, and planning for rehabilitation programs are recommended.

Causes of limb amputation among children differ between and within countries. These data are valuable in prevention and planning of rehabilitation strategies for the victims, but are seldom reported. The aim of this study was to investigate causes of amputation in children and adolescents in rural Kenya.

JULIUS OGENG'O, PhD, MOSES OBIMBO, MBChB, AND SARAH WANDIA NJOGU, are affiliated with the Department of Human Anatomy, University of Nairobi, Nairobi, Kenya.

JOHN KINGORI, MBChB, MMeD Ortho, is affiliated with the PCEA Kikuyu Mission Hospital, Kikuyu, Kenya.

Disclosure: There authors declare no conflict of interest.

Correspondence to: Julius A. Ogeng'o, BSc, MBChB, PhD, Department of Human Anatomy, University of Nairobi, Riverside Drive, PO Box 30197, 00100, Nairobi, Kenya; e-mail: jogengo@uonbi.ac.ke

Indications for amputation in children differ from those in adults1 and vary between and within countries.2,3 In Africa, most studies on amputation have been performed in Nigeria on adults,4 and little published data exist on children. In Kenya, two recent studies revealed conflicting results, with one reporting trauma and tumors as leading causes5 and the other finding congenital malformations as the leading cause.6 Further, in general, child amputees have fewer complications, better outcomes,7 are more likely to be successfully rehabilitated compared with the adults, and a large number will adapt well to their prostheses.8,9 In Africa, including Kenya, child rehabilitation centers for prosthetic fitting are few, probably due to scarcity of data to justify their establishment. Therefore, this study evaluated causes of amputation among children in two hospitals in rural Kenya.

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SUBJECTS AND METHODS

This was a descriptive retrospective study at two hospitals in rural Kenya, namely PCEA Kikuyu Hospital in Central and Tenwek Hospital in Rift Valley Provinces. Both of them are level 4 referral mission hospitals with a 300-bed capacity and at least one specialist surgeon. They provide care for lower middle class natives mainly from two large ethnic groups, namely Kikuyu (PCEA Kikuyu) and Kalenjin (Tenwek). Each of them performs about 5 to 10 major surgical operations per week. Ethical approval to use patient data was obtained from respective Hospital Management Boards. Records of all amputation cases during the period of January 1998 to December 2008 were retrieved. Patients aged 18 years and younger were selected and grouped into male and female. They were then categorized into six age groups: 0 to 2, 3 to 5, 6 to 8, 9 to 11, 12 to 14, and ≥15 years. For each age group, the cases were analyzed for cause in five categories: trauma, congenital defects, infection, tumor, and others. In cases where a major cause had more than three subcauses, it was also subclassified. Only files of patients who had complete medical records for age and cause were included. Those without age and confirmed diagnosis were excluded.

Data collected were analyzed using the statistical package for social sciences for Windows version 11.50 (SPSS Inc., Chicago, IL). Descriptive statistics were applied to determine means, frequencies, and ranges. A confidence interval of 95% was assumed, and the difference was considered significant at p ≤ 0.005. Results are presented using tables, graphs, and pie charts.

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RESULTS

Two hundred and ninety patients underwent 302 amputations at the two hospitals. Eighty-eight (30.3%; 60 males:28 females) of these were in children and adolescents aged 2 weeks to 18 years. Male:female ratio was 2:1. The overall mean age was 9.13 years, varying with cause. A total of 77.3% were older than 5 years. The most involved age group was 15 to 18 (23.8%), followed by 9 to 11 and 12 to 14 years (21.6%), whereas the least was 6 to 8 years (Table 1).

Table 1

Table 1

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CAUSES

Trauma was the leading cause (42%), followed by congenital defects (29.5%), infection (12.5%), and tumors (11.4%). Peripheral vascular disease was the least common (1.5%) cause. One case (1.5%) was because of ischemia after a very tight plaster (Figure 1).

Figure 1.

Figure 1.

Of the 42% traumatic causes, burns were the most common (27%), followed by animal bites (18.9%), road traffic accidents (RTA; 16.2%), falls from a height (13.5%), and cuts (10.8%). Violence and bomb blast affected one person in each case (Figure 2).

Figure 2.

Figure 2.

Congenital defects contributed to 29.5% of the cases (Figure 3). Of these, congenital pseudoarthrosis was the most common (23%), followed by complications of spina bifida (19.2%), macrodactyly (15.4%), and polydactyly (15.4%; Table 2).

Figure 3.

Figure 3.

Table 2

Table 2

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).

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DISCUSSION

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.

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CAUSES

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).

Table 3

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.

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CONCLUSION

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.

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ACKNOWLEDGMENTS

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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REFERENCES

1. Paudel B, Shrestha BK, Banskota AK. Two faces of major lower limb amputations. Kathmandu Univ Med J (KUMJ) 2005;3:212–216.
2. Akinyoola Al, Oginni LM, Adegbehingbe OO, et al. Causes of limb amputations in Nigerian children. West Afr J Med 2006;25:273–275.
3. Banza LN, Mkandawire NC, Harrison WJ. Amputation in children: an analysis of fluency and cause of early wound problems. Trop Doct 2009;39:129–132.
4. Thanni LO, Tade AO. Extremity amputation in Nigeria—a review of indications and mortality. Surgeon 2007;5:213–217.
5. Awori KO, Atinga JEO. Lower limb amputations at the Kenyatta National Hospital. Nairobi East Afr Med J 2007;84:121–126.
6. Ogeng'o JA, Obimbo MM, King'ori J. Pattern of limb amputation in a Kenyan rural hospital. Int Orth 2009;33:1449–1453.
7. Yinusa W, Ugbeye ME. Problems of amputation surgery in a developing country. Int Orth 2003;27:121–124.
8. Boonstra AM, Rijnders LJ, Groothoff JW, Eisma WH. Children with congenital deficiencies or acquired amputations of the lower limbs: functional aspects. Prosthet Orthot Int 2000;24:19–27.
9. Kuyper MA, Breedijk M, Mulders AH, et al. Prosthetic management of children in the Netherlands with upper limb deficiencies. Prosthet Orthot Int 2001;23:228–234.
10. Muyembe VM, Muhinga MN. Major limb amputation at provincial general hospital in Kenya. East Afr Med J 1999;76:163–166.
11. Jones LE. The free limb scheme and the limb deficient child in Australia. Aust Paediatr J 1988;24:290–294.
12. Norberg E. Injuries as a public health problem in Sub-Saharan Africa: epidemiology and prospects for control. East Afr Med J 2000;77(12 Suppl):1–43.
13. Rijnders LJ, Boonstra AM, Groothoff JW, et al. Lower limb deficient children in the Netherlands: epidemiological aspects. Prosthet Orthot Int 2000;24:13–18.
14. Al-Worikat AF, Dameh W. Children with limb deficiencies: demographic characteristics. Prosthet Orthot Int 2008;32:23–28.
15. Yakubu A, Muhammad I, Mabogunje O. Limb amputation in children in Zaria Nigeria. Ann Trop Paediatr 1995;15:163–165.
16. Mwaura LW, Katsivo MN, Amuyunzu M, Muniu E. Childhood accidents in an urban community in Kenya. East Afr Med J 1994;71:506–509.
17. Yowler CJ, Mozingo DW, Ryan JB, Pruitt BA Jr. Factors contributing to delayed extremity amputation in burn patients. J Trauma 1998;45:522–526.
18. Loro A, Franceschi F. Prevalence and causal conditions for amputation surgery in third world: ten years experience at Dodoma regional Hospital Tanzania. Prosth Orthot Int 1999;23:217–224.
19. Dissanaike S, Boshart K, Coleman A, et al. Cooking-related paediatric burns: risk factors and the role of differential cooling rate among commonly implicated substances. J Burn Care Res 2009;30:593–598.
20. Kennedy PJ, Young WM, Deva AK, Hertsch PA. Burns and amputations: a 24-year experience. J Burn Care Res 2006;27:183–188.
21. Muguti GI, Maramba A, Washaya CT. Snake bite in Zimbabwe: a clinical study with emphasis on the need for antivenom. Cent Afr J Medicine 1994;40:83–88.
22. Chippaux JP, Kambewasso A. [Snake bites and antivenom availability in the urban community in Niamey Niger.] Bull Soc Pathol Exot 2002;95:181–183; in French.
23. Olawale OA, Owoaje ET. Incidence and patens of injuries among residents of a rural area in South-West Nigeria: a community-based study. BMC Public Health 2007;7:246.
24. Larson CF, Mulders S, Johansen AM, Stain C. The epidemiology of hand injuries in the Netherlands and Denmark. Eur J Epidemiol 2004;19:323–327.
25. Moshiro C, Heuch I, Astrom AN, et al. Injury morbidity in an urban and a rural area in Tanzania: an epidemiological survey. BMC Public Health 2005;5:11.
26. Kaisha WO, Khainga S. Causes and pattern of unilateral hand injuries. East Afr Med J 2008;85:123–128.
27. Yu KL, Bong CN, Huang MC, et al. The use of hospital medical records for child injury surveillance in Northern Malawi. Trop Doct 2009;39:170–172.
28. Ogunjumo DO. The clinical pattern of chronic pyogenic osteomyelitis in a Nigerian community. J Trop Med Hyg 1982;85:187–194.
29. Key JA. Amputation for chronic osteomyelitis. J Bone Joint Surg Am 1944;24:350–355.
30. Agaja SB, Ayorinde RO. Chronic osteomyelitis in Ilorin, Nigeria. S Afr J Surg 2008;46:116–118.
Keywords:

amputation; children; rural; Africa; Kenya

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