most patients with fractures present first to the traditional bonesetters before coming to the hospital ; it is therefore apt that we do not ignore this level of care . this practice is usually within the family circle from father to son and sometimes extended family members with other people being trained through apprenticeship . the challenge of the orthopedic surgeon is the attendant complications that are presented to him after the patient has been mismanaged by the tbs . some of these complications include limb gangrene following very tight local splints , malunion , nonunion , osteomyelitis , contractures , and limb length discrepancies . despite these complications , the demand for tbs services remains on the increase with some patients on admission in orthodox hospitals opting for treatment by a tbs . we set out to ascertain the reasons for the patronage of tbs by patients with fractures and assess patients impressions of them after the treatment . this was a prospective study done at the university of calabar teaching hospital , calabar . seventy - nine patients who presented at orthopedic out - patient clinic after attending traditional bone setting centers were recruited for the study . a predesigned questionnaire was filled containing details about the demographic data of the patient , presentation to hospital before resorting to the tbs , reasons for patronizing tbs , duration of treatment at bonesetters centers , sponsors of the treatment , introduction to the tbs , reasons for returning to hospital if patient had presented initially to the hospital , impressions about outcome of treatment by the bone setters and finally , patient 's advice to others who have similar conditions . the age range was 1783 years with a mean age of 36.8  11.8 years . forty - six ( 58.2% ) patients were married , 32 ( 40.5% ) were single , while only one ( 1.3% ) was widowed . there were 12 ( 15.2% ) students , 9 ( 11.4% ) artisans , and 16 ( 20.3% ) business men / women . the others were 17 ( 21.5% ) civil servants , 5 ( 6.3% ) farmers , and 2 ( 2.5% ) drivers . the educational status of the patients was as follows : primary education ( number [ n ] = 14 ; 17.7% ) ; secondary education ( n = 19 ; 24.1% ) ; tertiary education ( n = 44 ; 55.7% ) ; and no education ( n = 2 ; 2.5% ) . others were falls from height ( n = 15 ; 19.0% ) , domestic falls ( n = 2 ; 2.5% ) , gunshots ( n = 2 ; 2.5% ) , and assaults ( n = 2 ; 2.5% ) . of the 79 patients that consented for the study , 37 ( 46.8% ) accessed the hospital before patronizing tbs while 42 ( 53.2% ) did not . the factors that influenced the decision to patronize the tbs [ table 2 ] are as follows : delay of treatment at hospital 5 ( 6.3% ) , not satisfied with hospital treatment 5 ( 6.3% ) , poor attitude of hospital staff 2 ( 2.5% ) , tbs are more competent 12 ( 15.2% ) , tbs fee being cheap 11 ( 13.9% ) , patients having faith in tbs 16 ( 20.3% ) , sponsors of treatment took the decision 19 ( 24.1% ) , brought to tbs against patient wish 5 ( 6.3% ) , unconscious when brought 2 ( 2.5% ) , and fear of amputation 2 ( 2.5% ) . only occupation was significantly associated with reasons for the patronage of tbs ( p = 0.047 ) [ table 3 ] . the duration of tbs treatment ranged from 1 to 6 months with a mean of 2.5 months . more than half 39 ( 49.4% ) of the patients were introduced to tbs by family members , 34 ( 43.0% ) by friends , neighbors 2 ( 2.5% ) , unknown persons 2 ( 2.5% ) , hospital staff 1 ( 1.3% ) , and self 1 ( 1.3% ) . the opinion of patients about outcome of tbs treatment as shown in table 4 is as follows ; hospital treatment more reliable 7 ( 8.9% ) , tbs are not competent 8 ( 10.1% ) , no one should go to tbs 32 ( 40.5% ) , competency of tbs 2 ( 2.5% ) , regret seeking treatment from tbs 12 ( 15.2% ) , tbs operating on trial and error 6 ( 7.6% ) , hospitals are more competent 2 ( 2.5% ) , hospitals and tbs are good and no comment 5 ( 6.3% ) , 5 ( 6.3% ) , respectively . types of injuries among traditional bone setters attendants ( percentage ) sociodemographic characteristics of patients factors that influenced the patients decision to patronize traditional bone setters bivariate analysis of factors associated with traditional bone setters patronage and sociodemographics general opinions of patients about traditional bone setters on treatment outcome tbs still command the attention of most patients with fracture injury in west africa sub - region . treatment of a fractures by a tbs is natural to the average nigerian irrespective of his level of education because the practice appears to be ingrained in the minds of people being what most people were born to see practiced commonly in this part of the world and the world generally for over 3000 years . cultural and spiritual beliefs play a central role in the orientation of the people and their patronage of the tbs , as they consider the treatment as having a supernatural touch from the gods bringing about the healing of the bone . although several complications follow the treatment by these tbs , the strong belief in the spirituality associated with their activities encourages patient to continue patronizing them . the orthopedic surgeon today is constantly faced with the challenge of managing the attendant complications caused by the treatment of these tbs . in this study , young adult males constitute the bulk of those who patronized the tbs ( 59.5% ) with the mean age of 36.8  17.8 . the duration of stay with the tbs was between 1 and 6 months with a mean of 2.5 months . this age group constitutes the workforce in any society and spending such time with tbs with no solution at the end of the treatment but rather ending up with complications is gross loss of man hours with resultant reduction in productivity . their introduction to the tbs was most times from family members ( 49.4% ) and friends ( 43% ) , the result is similar with that by ogunlusi et al . , who had 85.2% from middlemen and also solagberu 's work stating that external persons formed 75% of sources influencing contact with tbs . this is because , in nigeria , there is still strong family bonds which allow extended family members and friends to influence very important decisions of an individual . the majority of these patients ( 55.7% ) were those who had attained tertiary education which affirms the fact that educational attainment has not really changed the cultural beliefs that the tbs are better in the management of any bone injury . this was different from the study by other authors and that of udosen et al . where there was up to 50% illiterate motorcycle riders forming the bulk of those who patronized the tbs . forty - two patients ( 53.2% ) were seen first by the tbs before presenting to the hospital ; this could have probably included some of the patients with open fractures which end up mismanaged with resultant wound infections and some with chronic osteomyelitis . where 79.3% of the patients visited tbs from the scene of the accident before presenting in the hospital . of utmost concern are the 46.8% of them who presented first for orthodox medical attention and were later taken away to the tbs because of unsatisfactory attention given to them by health care providers . health - care providers need to review the attitudes of staff to patients and also ensure that prompt attention is given to patients on arrival at the health center . the study reveals that 24.1% of the patients actually visited the tbs because of their sponsors who had to pay for their treatment ; this buttresses the fact that apart from the cultural beliefs , poverty plays a central role in the continued patronage of tbs . another group constituting 20.3% of the those who visited the tbs did so because of their beliefs that they are more competent ( 15.2% ) , this has been documented by many other authors . tbs being cheaper constituted 13.9% which also underscores the issue of poverty and the dependence on sponsors for treatment no matter where it is obtained . others visited the tbs because of the delay in orthodox care and poor attitude of orthodox caregivers . the fear of amputation ( 2.5% ) was the least in their reasons for patronage of tbs , which is different from reasons documented by some authors who had fear of amputation as one of the significant reasons for visiting the tbs . the tbs managed the different bone injuries that presented to them with the use of herbal concoctions , wooden splints , fresh palm leaves , and some scarifications and application of special herbal balms . the different impressions of the respondents about the outcome of tbs treatment were as follows : 40.5% concluded that no one should patronize tbs while 15.2% regretted ever being managed by the tbs , others felt orthodox medicine is more reliable . however , there was still a 6.3% group who believed that both the tbs and orthodox medical practitioner are the same , and hence they could still visit either of them . with recent advancements in the practice of orthopedics and trauma , there is still a very high patronage of the tbs by most of our patients irrespective of their educational status and position in the society . the reasons here are largely due to an external locus of decision making for the patient owing to their financial constraints with associated influenced of cultural and religious beliefs in the tbs . the present state of our hospitals also leaves nothing to be desired , as the patients wait endlessly for simple surgical procedures which are not done due to poor attitude of staff and undue delays . most patients impressions about the outcome of treatment by tbs were that they were not competent , not reliable and many regretted ever seeking help from them , though few were still indecisive . it is , therefore , pertinent that the relevant institutions of government ensure that the national health insurance scheme becomes fully operational to make health care affordable to all , especially trauma and orthopedic conditions that are relatively expensive .