By Dissertation Submitted to the Rajiv Gandhi University Of ...

MANAGEMENT OF BAHIR PRAKOSHTASTHI BHAGNA (COLLE’S FRACTURE)

WITH LAKSHA KSHEERA AND MANJISTADI LEPA

By

Dr. VIJITH V. NANGELIL

Dissertation Submitted to the

Rajiv Gandhi University Of Health Sciences,Bangalore,Karnataka

In partial fulfilment of the requirements for the degree of

Ayurveda Vachaspathi

M.S. (AYURVEDA)

in

Shalya Tantra

Under the guidance of

Dr.MANONMANI L M.D (Shalya),

H.O.D, Shalya Tantra

T.M.A.E’S AMC, Hospet

&

Under the Co-guidance of

Dr.RADHA B.K M.S (Ayu)

Asst.proffessor, Shalya Tantra

T.M.A.E’S AMC, Hospet

DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA

T.M.A.E. SOCIETY’S AYURVEDIC MEDICAL COLLEGE& HOSPITAL

HOSPET – 583 201

2014




HOSPET – 583 201

(Affiliated to Rajiv Gandhi University Of Health Sciences,Bangalore,Karnataka)

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “ Management Of Bahir

Prakoshtasthi Bhagna (Colle’s Fracture) with Laksha Ksheera And Manjistadi

Lepa” is a bonafide research work done by “Dr. Vijith V. Nangelil ” in partial

fulfilment for the degree of Ayurveda Vachaspathi (Master of Surgery) in Shalya

Tantra.

Date:

Place: Hosepet Dr.MANONMANI L M.D(Shalya)

Professor and H.O.D

P G Studies in Shalya Tantra,

T.M.A.E. Society’s Ayurvedic Medical

College, Hosepet.




HOSPET – 583 201


CERTIFICATE BY THE CO-GUIDE



Lepa” is a bonafide research work done by “Dr. Vijith V. Nangelil ” in partial

fulfilment for the degree of Ayurveda Vachaspathi (Master of Surgery) in Shalya

Tantra.

Date:

Place: Hosepet Dr Radha B.K M.S(Ayu)

Asst. Professor and P.G Guide

P G Studies in Shalya Tantra,

T.M.A.E. Society’s Ayurvedic Medical

College, Hosepet.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE,KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation / thesis entitled “ Management Of Bahir

Prakoshtasthi Bhagna (Colle’s Fracture) with Laksha Ksheera And Manjistadi Lepa”

is a bonafide and genuine research work carried out by me under the guidance of

Dr.MANONMANI M.D(Ayu), Professor & HOD, and Dr Radha B.K M.S(Ayu) Asst

Professor & Co Guide, Department Of Post Graduate Studies In Shalya Tantra,T.M.A.E.

Society’s Ayurvedic Medical College,Hosepet.

Date: Dr. VIJITH V. NANGELIL

Place: Hosepet

DEPARTMENT OF POST GRADUATE STUDIES IN

SHALYA TANTRA


HOSPET – 583 201


ENDORSEMENT BY THE H O D, PRINCIPAL / HEAD OF THE

INSTITUTION



Lepa” is a bonafide research work done by “Dr. Vijith V. Nangelil ” under the

guidance of Dr.MANONMANI Professor and HOD, Department Of Post Graduate

Studies In Shalya Tantra,T.M.A.E. Society’s Ayurvedic Medical College,Hosepet.

Seal & signature of the H.O.D Seal & signature of the Principal

Guide Principal

Dr. MANONMANI L M.D(Ayu) Dr. Dr. MANONMANI L M.D(Ayu)

Professor and HOD Principal

Dept. of P G Studies in Shalya Tantra, T.M.A.E. Society’s Ayurvedic Medical

T.M.A.E. Society’s Ayurvedic Medical College, Hosepet.

College, Hosepet.

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that this dessetation / thesis entitled “ A clinical study in Rajiv

Gandhi University of Health Sciences, Karnataka shall have the rights to preserve, use

and disseminate this dissertation / thesis in print or electronic format for academic /

research purpose.

Hosepet Dr. Vijith V. Nangelil

© Rajiv Gandhi University of Health Sciences, Karnataka.

OM NAMAMI DHANVANTHARI

ACKNOWLEDGEMENT

I offer my sincere devotion to LORD DHANWANTHARI for showering his

blessings and who gave me strength.

I record my indebtedness to my beloved parents Shri Dr.Vijayan nangelil,

Smt Dr.Jaya Vijayan for their untiring support and out lasting affection.

I feel very fortune enough to work under the guidance of Dr.ManonmaniL

M.D (Shalya) my Guide & Head of the department Shalyatantra,. for her functional

freedom, encouragement, support and sharpening my professional skills. I offer my

extreme thanks and deep sense of gratitude to my teacher.

I express my deep sense of gratitude to Dr Radha B.K M.S, Asst Professor &

Co-Guide,Department of ShalyaTantra,for her support for her untiring help and

constant attention and affection.

I convey my sincere gratitude to my beloved incharge Principal, my teacher

Dr. Chandra Shekar Rogi M.D (Ayu) & Asst. Professer Dr.B.B Bhatt M.S(Ayu) ,

Dr. Shariffuddin M.S(Ayu) department of P.G studies in Shalya Tantra T.M.A.E

Society’s Ayurveda Medical College and Hospital whose valuable timely suggestions,

untiring encouragement and unforgettable parental affection.

I am grateful thanks to my classmates, my junior friends of my department for

their good co-operation and support.

I express my sincere gratitude to all the faculty members of the institution, and

offer my sincere thanks to all my patients and who have rendered their wholehearted

support.

Date :

Hosepet Dr.Vijith V.Nangelil

CONTENTS

Page No.

I. Introduction 1 – 4

II. Objectives 5

III. Review of Literature

(a) On Ayurveda 6 – 34

(b) On Modern 35 – 46

(c) On Drugs 47 – 57

IV. Methodology 58 – 63

V. Observations &Results 64 - 71

VI. Discussion 72 – 86

VII. Conclusion 87

VIII. Summary 88

IX. Bibliography 89 – 91

X. Annexure (case proforma) 92 – 95

i

LIST OF TABLES/GRAPHS

S.No Name of the Tables/Graphs Page No

01 Showing the Effect Of Trauma on Bones 13

02 Showing the Classification of Kandabhagna 14

03 Showing the Classification of Sandhimukta. 14

04 Showing the Sushruta's Classification with Modern 22

05 Showing the Drugs used for Lepa 55

06 Showing the Drugs used for ksheerapaka 55

07 Showing the Age wise distribution of the Patients 61

08 Showing the Sex wise distribution of the patients 61

09 Showing the Distribution of patients on the basis of their religion 62

10 Showing the Occupation wise distribution of patients 63

11 Showing the Distribution of patients on the basis of locality 63

12 Showing the Incidence of patients as per their prakruthi 64

13 Showing the Incidence rate of mode of injury 64

14 Showing the Incidence rate of Side of involvement of hand 65

15 Showing the Site of involvement of Radius 66

16 Showing the Effect of therapy on Pain 67

17 Showing the Effect of therapy on swelling 67

18 Showing the Effect of therapy on Tenderness. 67

19 Showing the Effect of therapy on loss of function 68

20 Showing the Effect of therapy on callous 68

21 Showing the statistical analysis of symptoms after treatment 68

22 Showing the statistical analysis of symptom before and after treatment 69

ii

FIGURES

1. Karkata Bhagna

2. Ashwkarna Bhagna

3. Churnita Bhagna

4. Pichhit Bhagna

5. Asthichalitha Bhagna

6. Kanda Bhagna

7. Majjanugata Bhagna

8. Atipatita Bhagna

9. Vakara Bhagna

10. Chinna Bhagna

11. Patita Bhagna

12. Sphutia Bhagna

13. Anchana

14. Pidana

15. Sankshepana

16. Bandhana

17. Mritpinda Dharana

18. Lavana Dharana

19. Pashana Dharana

20. Bone cells

21. Compact and Spongy bone

22. Compact bone structure

23. Spongy bone structure

24. Classification of the bones

25. Structure of the long bone

26. Structure of the short bone

27. Structure of the flat bone

28. Structure of the irregular bone

29. Mechanism of fracture by compression

30. Mechanism of fracture by angulation

31. Mechanism of fracture by tension

iii

32. Mechanism of fracture by rotation

33. Mechanism of fracture by shearing

34. Transverse fracture

35. Spiral fracture

36. Oblique fracture

37. Comminuted fracture

38. Compression fracture

39. Simple or Closed fracture

40. Open or Compound fracture

41. Traumatic fracture

42. Pathological fracture

43. Stress fracture

44. Single fracture

45. Multiple fracture

46. Undisplaced fracture

47. Displaced fracture

48. Infarction fracture

49. Greenstick fracture

50. Torus or Buckle fracture

51. Bending mechanism of fracture

52. Three point bending mechanism of fracture

53. Four point bending mechanism of fracture

54. Compression and bending of fracture

55. Bone healing

56. Manjishata- a) Plant, b) Stem, c) Powder

57. Yashtimadhu - a) Plant, b) Stem, c) Powder

58. Shali a) Plant b) Grains

59. a ) Gritha, b) Shathadhauta gritha

60. Raktachandana a) Plant, b) Stem

61. Grshata Ksheera

62. Laksha Powder

63. Udumbara

iv

64. Ashwatha

65. Palasha

66. Drugs used for Lepa

67. Application of a) Lepa, , b) Splints, c) bandha

68. Ksheera paka

69. Follow up x- rays

v

OBJECTIVES

MANAGEMENT OF BAHIR PRAKOSHTASTHI BHAGNA (COLLES’ FRACTURE)

WITH LAKSHAKSHEERA AND MANJISTADI LEPA

5

AIMS AND OBJECTIVES OF THE STUDY

“To evaluate the efficacy of Ayurvedic management on Colle’s fracture”

The objectives of the study includes:

1. Restoration of anatomy of wrist and forearm.

2. Early reduction of pain and swelling by external application.

3. Effectiveness in allowing early mobilization and rehabilitation.

4. Reduction of immobilization period by giving Laksha Ksheerapaka internally and

Manjistadhi Lepa externally.

INTRODUCTION



1

INTRODUCTION

The practical knowledge along with the theoretical knowledge is very much

essential. Whatever is seen while doing practical study and going through concerned

literature , adds the knowledge when both are applied together. Keeping these golden

words of Sushruta the following study is carried out.

The population based incidence of work-related fractures and associated risk

factors have not been well documented. It is identified that incidence rate of fracture was

highest in the agricultural sector (194.5 per 10,000 workers), followed by mining (168.8

per 10,000 workers), construction (111.7 per 10,000 workers) and manufacturing (87.5

per 10,000 workers). In each industrial sector, males had significantly higher incidence

rate than females except for the educational sector. (Ref: Incidence and Risk of Work-

related Fracture Injuries: Experience of a State Managed Workers Compensation

System—Islam SS, Biswas RS, Nambiar AM, Syamlal G, Velilla AM, Doyle EJ,

Ducatman AM). So the problem faced by the medical practitioner regarding fractures and

dislocations provide much scope for systematic study.

Ayurveda is the upaveda of Atharvanaveda which deals with science of life. This

science is valuable heritage of India. Almost all types of therapies are described

comprehensively in Ayurvedic texts. The art of healing of the ailments has been known

from the time immemorial. Many indigenous ways and methods have been followed for

the relief of suffering of man kind since Veda's. The reference of trauma is as old as the

beginning of human being.

Traumatic surgery has been in practice since Vedic period. Ashwini Kumaras

used to perform surgeries like limb replacement, fixation of severed head, transplantation

of eyes and teeth etc. The same science is developed, practiced, and well documented by

'Famous Indian surgeon Acharya Sushruta'. He deserves the credit of classifying skeletal

injuries into various groups. This classification has been done on the basis of anatomical

variations and prognostic values for ensuring proper management. Elaborate description

INTRODUCTION



2

of this branch of surgery is available in his treatise-"Sushruta Samhita". After going

through the chapters of bone injuries in this book one cannot resist in forming a positive

opinion about the most systematic and extensive study of these cases made by him. Now

the methods of management of fractures have been modified greatly. But the principles of

diagnosis of fractures and treatment laid down by Sushruta still hold good and deserve

appreciation. The Sushruta Samhita is considered as a treasure of time-tested surgical

knowledge which has been proved to be valuable resource for treatment and guiding the

research in present surgical era. The present status of Modern surgery has reached the

summit of progress in all aspects. In spite of this there are many challenges to be taken

up. The world of medical scientists is anxiously scanning the Ayurvedic surgery as an

alternative.

Bhagna it is an epitome were bone or bones get interrupted. This is classified on

the basis of its clinical importance in to Avrana (Simple fracture) and Savrana

(Compound fracture).In modern literature, a fracture is defined as a break or loss of

continuity in the substance of the bone.

Acharya Sushruta has advocated the principles of reducing the fracture. They are

Anchana (Traction), Peedana (Manipulation), Sankeshpana (Opposition), and Bandhana

(Immobilization) which is practiced regularly even today. In modern orthopedics the

simple fractures are managed by closed reduction followed by application of POP. The

hazards of POP are Pain, Pressure sore, Compartmental syndrome, Nerve compression,

Plaster blisters, etc.Considering the above problems, we are justified to find out a binding

material to attain immobilization without much complications the Lepa is selected in the

present study.

All this has been the inspiration for undertaking the study pertaining to traumatic

surgery of Ayurveda. Throughout India till now 212 P.G. dissertations and 48 Ph.D.

works are carried out in post graduate department of Shalyatantra at various institutes

from 1966 to 1996,out of which 27 P.G. dissertations and 1 Ph.D. work is related to the

traumatic orthopedic surgery. In Rajiv Gandhi University of health sciences from 1996 to

INTRODUCTION



3

1999, 25 dissertations in postgraduate department of Shalyatantra are submitted out of

which 1work is related to Bhagna Chikitsa.

Everyday 40-50% cases of surgical OPD are suffering from such types of

ailments. Few traditional practitioners specifically dealing with fractures, called 'Bone

setters', have been effectively using herbo-mineral drugs over many centuries. Many of

these drugs are simple, easily available, cost effective and potent.

The scientific evaluation of such drugs along with their fundamental principles is

essential for their universal acceptance. Hence in this study an attempt is made to put

forth such principles of Sushruta and the preparations like Lepa and Ksheerapaka for the

clinical trial. In the present study the comparison between contemporary management of

simple fractures with that of Sushruta's technique is made. It has been also tried to assess

the efficacy of these Ayurvedic drugs in bone healing and in providing symptomatic

relief.

The thesis is discussed under these headings.

Ayurvedic literature review: In this chapter Asthi shareera,Bhagna nirukti,

Classification of Bhagna,Bhagna Chikitsa is discussed in detail. A special effort has made

to assess Bhagna types radiolgically.

Modern literature review: In this chapter Bone anatomy, types of bones, fracture

classification, and its management is discussed in detail.

Drug-review: The drugs used for trial are reviewed in detail.

Materials and Methods: under this heading the materials used in the clinical trial and

methods adopted are explained in detail.

Results: The statistical analysis of the signs and symptoms before and after treatment of

both the groups is done in detail manner.

Discussion: It includes the discussion on the literature review, on materials and methods,

observations and on results.

INTRODUCTION



4

Summary and conclusions: Total work with its results are summarized under this

heading.

However the idea of the present work is to find out Management Of Bahir

Prakoshtasthi Bhagna (Colles’ Fracture) with Lakshaksheera And Manjistadi Lepa

and to open new way of treatment which is easily available, economical, as well as

minimize the problems of POP.

OBJECTIVES



5

AIMS AND OBJECTIVES OF THE STUDY

“To evaluate the efficacy of Ayurvedic management on Colle’s fracture”

The objectives of the study includes:

1. Restoration of anatomy of wrist and forearm.

2. Early reduction of pain and swelling by external application.

3. Effectiveness in allowing early mobilization and rehabilitation.

4. Reduction of immobilization period by giving Laksha Ksheerapaka internally and

Manjistadhi Lepa externally.

LITERATURE REVIEW



6

LITERATURE REVIEW

An approach to human ailments is as old as the evolution of human being. The

most ancient practiced medical science is Ayurveda. It is the fore runner of all the

therapies of the world, since man has thought of providing an effective remedy to the

diseases suffered by him.

Ayurveda or science of life describes prophylaxis, prevention, and therapeutic

principles for the diseases. This being the branch of Veda's it relates with knowledge of

philosophy, medicine, and art of surgery. Fore most surgeon of the world, Acharya

Sushruta, most revered physician Acharya Charaka and acharya Vagbhata are the

foundation tripods of Ayurveda. The texts conceived and devised by the honoured trio

have over the ages proved to be the baseline of reference for the knowledge of diseases

suffered by mankind.

The Ayurvedic philosophy is specific pertaining to the body constitution. The

human body (Shareera) is described as a combination of external factors the Atma1

(soul), Manas (mind) and Pancha maha bhoota (five mega elements). In all the living

beings the matter and energy is existing in the form of Dosha Dhatu & Mala . The most

important supportive framework of the body among these is Asthi (Bone tissue).

The branch of surgery that deals with deformities of the bones is known as

orthopedics. Orthopedic surgery has its aim the '' maintenance of normal mechanical

function of the deformed bones''. This part of the treatment in Ayurveda is called bhagna

Chikitsa. It was at its peak optimum level during the period of ancient famous Indian

surgeon Sushruta acharya. He has given clear and elaborate ideas about this branch.

The subject of this clinical reaserch is to evaluate Management Of Bahir Prakoshtasthi

Bhagna (Colles’ Fracture) with Lakshaksheera And Manjistadi Lepa. Hence it is must

to describe the literature about bhagna-Fractures, in this topic of literature review.

6

LITERATURE REVIEW



7

In this chapter first of all Ayurvedic literature is described and then the Modern

part of the literature are reviewed. In Ayurvedic literature about Asthi dhatu will be

described briefly.

The Nidana Panchaka part Patho physiology of bhagna will be discussed. Which

contains definition of bhagna, its etiology , classification, general features, special

features, and prognosis. The treatment of the fracture includes treatment principles then

specific treatment for different bones, clinical criteria's to assess bone healing, followed

by pathyaa pathya (Prophylactic do's and don'ts).

ASTHI SHAREERA

Asthi is one among seven dhatu- specific body constituents. It is more stable and

strong among seven dhatu.

Nirukti : The word Asthi is derived from Asthi-dhatu and Katina - pratyaya it means

stable and strong.

Paryaya : Keekasa, Kulyam, and Medoja

Utpattij : According to Sushruta Asthi starts developing during third month of

intrauterine life and totally organizes with complete manifestation in the seventh month

of gestation.

Embryology of bones : The embryo is formed by some important factors known as

bhava's. There are six bhava's namely matruja, pitruja, satwaja, satmyaja, Rasaja, Atmaja.

Amongst these Bhava's, Pitrujabhava is especially responsible for the formation of Asthi

in the embryo. According to Charaka, the bone formation in the embryological stage

takes place out of Panchamahabhoota having the dominance of Prithvi and Agni

[Chakrapani]. But Dalhana opines that there will be predominance of Prithvi , Agni and

vayu.

LITERATURE REVIEW



8

According to the sequence of dhatu in the body, Asthi is the fifth dhatu. It is

formed from the Sukshmabhaga of Medodhatu, by the action of Asthidhatwagni. Here

Medodhatu is acted upon by Agni which results in to a hard and dry substance having the

dominance of Prithvi, it is made porous and spongy by vayu. These pores are filled up by

sneha called Majja. One can appreciate the role of all Mahabhoota in Asthi. Like shallow

places are because of Akasha which is filled up by Jala Mahabhoota' in the form of

Majja. Ghanatwa is because of Prithvi, Laghutva by Vayu. and paka during the formation

is by the influence of Tejomahabhoota. Asthi posses the qualities like Guru, Katina,

Sthoola, Sthira, and predominantly constituted of Prithvimahabhoota.

Different analogies are there about the formation of dhatu, namely, Ksheera-

Dadhi Nyaya, Kedara-Kulya Nyaya. Asthi is the dhatu which does the Dharana of the

body. Medodhatu nourishes the Asthidhatu and in turn Asthidhatu nourishes Majjadhatu.

The strength of the Dhatvagni decides the formation of any dhatu. The formation of

Asthidhatu takes place from Medodhatu acted upon by Medodhatwagni. On the other

hand if the formation of Asthi is not proper or if it is not at all formed ,then it may be due

to improper state of Medodhatwagni. In the same way when Asthidhatwagni works,

Majjadhatu is formed . and when this Dhatvagni is not proper ,then Majjadhatu may not

form and may retard the formation of other Dhatu's.

Medas and Jaghana are the Moola of Asthivaha srotas. It is the channel through

which the nutrients are being circulated within the Asthidhatu.

Ativyayama, Abhighata, Vatala Ahara etc, are Nidanas, which vitiate these srotas

and results into Asthibheda, Adyasthi, Asthishoola etc. Bhagna is the one of the Vikaras

of Asthivahasrotodusthi, because of Abhighata depending on force of impact, the bones

of the particular part of the body will break in one or two, if subjected to sudden violent

injury.

LITERATURE REVIEW



9

ASTHI SANKHYA

Regarding the number of bones in the body, we find difference of opinions in the

classics.

Name of the Acharya's No. of bones

1. Sushruta 300

2. Vagbhata 360

3. Charaka 360

4. Bhavamishra 300

5. Sharangadhara 300

According to modern science the total numbers of bones in the body are 206.

These numerical difference in the bone is due to the different ideology such as counting

methods, inclusive of Teeth, Tubercles and facets etc.

ASTHI PRAKARA

Based on structures and shapes, different types are identified in the body.

Sushruta has classified Asthi into 5 varieties.

1. Kapalasthi (Flat Bones) e.g.- Scapula, Hipbone.

2. Ruchakasthi (Lustrous Bones) e.g.- Teeth

3. Tarunasthi (Cartilage) e.g.- Cartilage's of Ear

4. Vayalasthi (Curved Bones) e.g.- Ribs

5. Nalkasthi (LongBones) e.g.- Humerus, Femur.

LITERATURE REVIEW



10

ASTHI KARYA

Sushruta says that the body of the living beings stands by the support of the

bones, just as trees stand by support of their Sara. In the same manner the Asthi sustains

the human body.

According to Charaka the bones give a framework to the body and provide

nutrition to the majjadhatu. The shape, position, support and body performance basically

depends on the asthidhatu. Katina, sthira, and khara Guna protect the marma and at the

same time help the attachment of Mamsa Sira & Kandara etc .

Formation of the asthidhatu occurs in Asthivahastrotas. Asthidharakala and

Maladharakala are considered as same, as in the disorders of colon,the bony tissue gets

affected and the salts like calcium,Phosphorous etc , which build bony tissue are more

over getting absorbed in the colon. Some of the e.g.'s which tells the relation between

Asthidharakala and maladharakala in Ayurvedic texts like, Diarrhoea is the main

symptom in Asthikshaya. All these factors are to say that , the site of Asthidharakala has

an identical relation ship with the maladharakala.

HISTORICAL ASPECTS OF BHAGNA

Pre-samhita Period: The mechanism of repair following an injury to any tissue had

been known to man kind from time immemorial. To make injured tissue heal many

measures had been employed according to their knowledge and facilities available. The

trauma and its management, history goes back to earliest time of Rigveda (3500-1800

BC).More details of medicinal herbs and there usage in fracture healing are available in

Athaervaveda, here the precise reference of bone healing is first seen. Whitney (1962) in

his English translation of Athaervaveda quotes as '' Grower art though, grower; grower of

severed bone; make this grow, O Arundhati'', Let thy marrow come together with

marrow, and thy joint together with joint, together let what of thy flesh has fallen apart ,

together let thy bone grow over'', ''let marrow be put together with marrow, let skin grow

with skin; let thy blood , bone grow let flesh grow with flesh''.

LITERATURE REVIEW



11

The other reference of Koushika Sutra states about sprinkling of fractured part

with Laksha Quatha and healing enhancement of fracture is done by the intake of Laksha

Shruta Dugdha etc. Instantaneously Vishala's leg was replaced by Ayas (copper or iron),

when in the war she lost her leg and was able to fight the next day in war field. The

surgical science was much advanced with specialization subjects in various fields

including Orthopedics the same concept can also be ascertained with reference available

today for scientific approach of splints for bone setting.

Samhita Period: A vivid description of Aetiology, Classification, Symptomatology,

Prognosis, Complications and Management of fractures, are available in the ancient

surgical treatise like that of Sushruta Samhita (600BC) written by Acharya Sushruta. The

history of modern orthopedic surgery did not start before Hippocrates. He is believed to

have been born about 460BC. in the Island of COS. and died about 370 BC. At much

later period than Sushruta.

In Charaka Samhita Charakacharya has mentioned the setting of bone in 'Vrana

Context' only, but not as separate topic like Sushruta . But regarding the treatment of

fractures he has insisted to compare the fracture part with normal part. Charaka has not

classified the fractures like Sushruta. Vagbhata Acharya follows Sushruta's classification

of fractures mainly two types i.e. Sandhimuktha and Asandhibhagna. Vagbhata has the

significance of identifying the place of fractures and dislocations at the given differences

like sandhi and asandhi. However there is no much contradiction between both the

authors. Thus Vagbhata relates the terminology of Kandabhagna of Sushruta with the

possible name as Asandhibhagna.In addition to above Vagbhata contributes certain

variety of Yoga's like Lasunadi Taila & Gandha Taila etc.

Nighantu period: The Nigantu's like Yogaratnakara, Madhavakara and Bhavapraksha

etc. have followed Sushruta in relation with fracture classification. The additions they

have made in relation with therapeutics, like Lakshagodhumadi Yoga, Rasonadi Gugglu,

Lakshadi Gugglu, Shali saindhva yoga etc. While Bhavapraksha & Yogaratnakara have

LITERATURE REVIEW



12

mentioned different yoga's as well as suggested to use 'Panka' in Avaranabhagna in the

place of cotton before a splint as a buffer but no where it can be traced in Sushruta or

Charaka samhita. Other Nighantus like Kaiyadeva or Shodala, Madanapala etc. have not

mentioned about 'Bhagna' but mentioned about the drugs that are used to treat fractures,

under the name of Sandhaniya dravyas e.g. Arjuna. All this indicates the Nighantukaras

have accepted Sushruta's classification of bhagna with minimal alterations and in its

management they have added certain formulations and drugs .

BHAGNA - REVIEW

Shabdhotpatti : The Word Bhagna is derived from the word bhanj-dhatu and Katu-

pratyaya meaning to break Bhanj means motion, which once again means to break.

Vyakhyana: Bhanjayatithi bhagna || (Shabdasthoma nidhi).

Bhagna, can be defined as a phenomenon in which a bone or bones gets

interrupted. The word bhagna, in Ayurvedic texts refers to for both fractures and

dislocations. Bhagna is mainly classified in to two groups as Kandabhagna which is of

twelve (12) types. And sandhimukta is of six (6) types.

Paryaya: Bhagna, Bheda, Bhedana, Bhanjana, Vibhaga.

Nidana:

• Patana : Fall from height.

• Peedana : Violent pressure or compression.

• Prahara : Direct or indirect blow.

• Akshepana : Violent jerks.

• Vyalamrugadashana : Animal bites, Attacks of wild beasts.

• Balavadnigraha : Strong block from strong persons.

• Abhighatavishesha : Trauma caused by different causes.

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13

Great attention has been given by Acharya Sushruta towards aetiology, which is

still seen now a days. Vagbhata has also given the fracture causes in detail. While others

like Acharya Charaka, Bhavamishra, Madhavakara, Sharangdhra are silent. The

pathological fractures will occur due to the conditions like asthikshaya, majjakshaya,

asthividrudi, pakshaghata, phiranga, asthimajjagatakushta, asthimajjagatavata etc.

EFFECT OF TRAUMA ON BONES :

The bones sustain trauma in different ways. Acharya Sushruta has paid due

attention to this fact and observed that all the bones do not show similar type of effect to

the trauma. He has then classified these effects in different groups and correlated with the

types involved the same is mentioned below.

(TABLE-01)

1) Cartilages - Bend

2) Long bones -Break

3) Flat bones - Crack

4) Teeth - Fragmented

5) Curved bones - Crack or Break.

CLASSIFICATION OF BHAGNA

The classification of Bhagna given by Sushruta, Madhavakara, Chakradatta,

Bhavaprakash and Gadanigraha resembles each other. Vagbhata's opinion differs in this

regard. Charaka has not given any classification.

Sushruta's classification: The skeletal injuries have been divided on the basis of

structure involved as, 1) Sandhimukta 2) Kandabhagna.

Vagbhata's classification : Vagbhata has mentioned same classification in different

words as, 1) Sandhibhagna 2) Asandhibhagna.Apart from this classification Sushruta

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14

and Madhava has further divided the bhagna on the basis of their clinical manifestation

as:

1) Savrana bhagna (compound fracture) 2) Avrana bhagna ( closed fracture)

The dislocations have further been classified in to six varieties. And the fractures are

subdivided according to type of injury in to twelve types.

Classification of Kandabhagna : (TABLE No.02).

Name of

Bhagna

Sushruta Vagbhata

A.H.

Vagbhata

A.S.

Charak

a

Bhava

Prakasha

Madhav

a

Nidana

Sharang

adhara

Karkataka + + + --- + + ---

Ashwakarana + + + --- + + ---

Choornita + + + --- Vichoorni

ta

Vichoorn

ita

---

Picchita + + + --- + + ---

Asthichallita + + + --- + Asthichall

ika

---

Kandabhagna + Vellita Vellita --- + + ---

Majjanugata + + + --- + Majjagata ---

Atipatita + + + --- + + ---

Vakra + + + --- + + ---

Chinna + Shoshita Shoshita --- + + ---

Patita + Darita Darita --- + + ---

Sphutita + + + --- Visphutit

a

+ ---

Classification of Sandhimukta(TABLE No. 03)

Name of

Sandhimukta

Sushruta

samhita

Astanga

Hridaya

Astanga

Sangraha

Charak

a

Samhita

Sharan

gadhara

Bhava

prakash

Madhav

a Nidana

Utpistham + + + --- --- + +

Vishlistham + + + --- + + +

Vivartitam + + + --- + + +

Avakshiptam + + + --- --- + +

Atikshiptam + + + --- --- + +

Tiryakshipta

m

+ + + --- + + +

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15

The Sushruta's classification is followed by every one. Vagabhata has given

different terminology's for some varieties. He has mentioned Vellita in place of

Kandabhagna. Darita in the place of Patita and Shoshita at the place of Chinna. Acharya

Madhavakara has also used some other terminology like vichurnita at the place churnita.

Asthichallita at the place of Asthichallita and Majjagata at the place Majjanugata. He has

described Chinna is of two types: 1) Ekamanuvidaritam 2) Bahunuvidaritam.

Acharya Sharangadhara has not followed Sushruta's classification but he has

described the eight varieties of bhagna. These are similar to Sushruta's classification.

1) Bhagna prista 5) Adhogata

2) Vidarita 6) Urdhvagata and

3) Vivartita 7) Sanghibhagna.

4) Vishlishat 9) Tiryaka kshipata

CLINICAL FEATURES

The presence of fracture can be made out by history and clinical findings. The

clinical signs described in Ayurvedic texts stand the same as mentioned in any modern

surgical text book. The Sushruta's contribution in this aspect is so perfect that it has

hardly any room for alteration even today. He has mentioned signs and symptoms both

in general and specific.

GENERAL FEATURES OF 'KANDABHAGNA'

Shvayathubahulyam (Marked swelling) : Generally fracture, whether it is hair line

or comminuted, it will be associated with moderate to severe swelling.

Sparshasahisnutvam (Tenderness) : Tenderness is such a sign that it is invariably

present in all types of fractures.

Avapidyamane shabda (Crepitus) : Presence of the crepitus is a definite indicative

of fracture, can confirm diagnosis clinically.

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Vividhavedanapradurbhavah (Different types of pain ) : The fractured bone

before its reduction and immobilization produces variety of pain. This depends on

nature of trauma, bone fractured, displacements of the fragments, and nature of soft

tissue injury.

SarvasuAvasthasu Na Sharmalabha (Inability to get comfort in any position):

Fracture gives to pain and discomfort to the patient till immobilizing it. The

discomfort is such that patient remains restless in any posture of fractured part.

SPECIFIC FEATURES OF INDIVUDAL 'KANDABHAGNA'

(1) Karkataka (FIG -01)

The fracture which has a shape similar to 'crab' is named as Karkataka. The case

where the fractured bone is depressed at its two articular extremities and bulges out at the

middle, resemble the shape of gland is called as Karkataka.

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(2)Ashwakarana: (FIG -02)

Here fractured bone projects upwards like the ear of horse is called as Ashwakarana

(3)Churnitam : (FIG -03)

The fractured bone is found to be shattered into fragments or the powder form. This

Bhagna can be detected clinically by presence of crepitus.

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(4) Pichhitam : (FIG -04)

In this type of fractures, the bone is compressed between the two opposite forces, it gets

expanded transversely and marked swelling occurs.

(5) Asthichallita: (FIG -05)

In this type of fracture, the periosteum is splintered off, where the fracture fragment

slightly elevates into one side, as the bark gets away from the main stem.

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(6) Kanda bhagna : (FIG -06)

In this type of fracture the shaft of the bone is fractured. The fractured part shows

abnormal movement.

(7) Majjanugatam: (FIG -07)

In a fracture one fragment gets impacted into another causing displacement of bone

marrow, then it is said to be Majjanugatam. It may be resulted due to force of violence.

This type of fracture is very difficult to diagnose because the signs and symptoms like

transmitted movements crepitus etc. are absent due to impaction.

(8) Atipatitam : (FIG -08)

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A case where the fracture occurs throughout the plane of the bone is named as Atipatita.

Here the fragments are completely separated and the separated fragments hang or

angulated.

(9) Vakra : (FIG -09)

The bones get bent, but not broken, especially in tarunasthi's in children

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(10) Chinnam : (FIG -10)

The fracture in which the continuity of the bone is breached at one side while the other

side remains intact known as Chinnam.

(11) Patitam : (FIG -11)

A fracture in which bone is partially fractured and cracks in to multiple fissures

resulting into severe pain in the affected part.

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22

(12) Sputita : (Fig. 12)

will be pricking pain due to sharp points of bristles. Such type mostly occurs in small

bones and teeth etc.

SUSHRUTA'S CLASSIFICATION WITH NEAREST MODERN COMPARISON

TABLE No. 04

Karkataka : Depressed fracture.

Ashwakarana: Complete oblique fracture.

Churnitam : Comminuted fracture

Pichhitam : Fracture by compression.

Asthichallita : Sub periosteal avulsion.

Kanda bhagna : Complete spiral fracture.

Majjanugatam : Impacted fracture.

Atipatitam : Complete compound fracture.

Vakra : Green stick fracture.

Chinnam : Incomplete fracture.

Patitam : Comminuted fracture flat bones.

Sputita : Fissured fracture.

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The above mentioned classification of fractures is described by Sushruta Acharya

. This indicates his accuracy in clinical diagnosis. He has classified those varieties

merely on clinical assessment, such as according to position of broken fragments, site of

fracture, direction of force, and from the deformity caused by broken fragments. While

classifying the types of fractures he did not include only the varieties of fracture known

and compared today but also added even his minute observations like periosteal avulsion.

In fact Sushruta has viewed fractures as " Bone Injuries" in the true sense and not merely

as the discontinuity in the surface of the bone.

Prognosis

Acharya Sushruta has described the prognosis of fractures in to Sukhasadhya,

Kastasadhya, and Asadhya after considering the following points:

1) Prognosis. 5) Site of fracture

2) Seasonal Variation 6) status of bone

3) Age 7) Type of fracture

4) Status of Patient

SEASONAL VARIATION

AGE P

R

O

G

N

O

S

I

S

STATUS OF

PATIENT

SITE OF

FRACTURE STATUS OF

BONE

TYPE OF

FRACTURE

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Aacharya Sushruta has described that cures are effected with extreme difficulty in

Churnita Bhagna (Comminuted#),ChinnaBhagna (Incomplete#), Atipatita Bhagna

(Complete #), Majjanugata Bhagna (Impacted #) and in Intraarticular Fractures.

The fractures occurring in (1) Paediatric age group (2) Frail and emaciated

persons (3)Individuals suffering with Dermatological , Asthmatic anomalies and other

supervening disorders (4) A person with intemperate habits or Vatika temperament or

who is sparing in his diet have also poor prognosis.

The Following Fractures have Guarded Prognosis (Asadhya):

(1)Complete fracture and dislocation of Pelvic bone with displacement.

(2) Comminuted (Churnita) fractures of Iliac bone and Frontal bone.

(3)Dislocations of the cranial bones.

(4)Fracture of sternum, temporal bone, vertebral column and cranium.

The bone or joint having congenital anomaly, diseased bone, fracture of bones

which was reduced properly but displaced due to improper immobilization or improper

bandaging, or if the fractured part is disturbed, all these circumstances leads to failure of

treatment.

The fractures treated by an expert surgeon get properly united if the- it occurs at

the first three stages of life (childhood, adolescence, adult).

The management of fractures is difficulty in the patients who consumes excessive

Lavan, Katu, Kshara, Amala dravyas etc. Also one who is performing Vyayama,

Maithuna, etc.

Complications

Acharya Dalhana has mentioned, the complications22 of the bone injury may be

(1) Local or (2) Systemic.

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25

(1) Local complications are Malunion and Fragmented Fracture. The variety of

complication which could occur due to tight bandaging is swelling, pain, avascularization

and gangrene

(2) Systemic complications are Fever, Abdominal distension, and Cessation of passages

of excreta like urine and feces .

BHAGNA CHIKITSA

The ancient Ayurvedic texts have described ' Asthibhagna Chikitsa' thoroughly. This

includes :

(1) Principles of Bhagna Chikitsa.

(2) General Management of Bhagna.

(3) Specific Management for different types of fractures.

(4) Medicinal preparations for different kinds of fractures.

(5) Pathyaa-Pathya.

(6) Clinical criteria of fracture healing.

(1) Principles of Bhagna Chikitsa

The management of the case will be always changing. What is accepted as the

best type today is found to be modified tomorrow. It is always devised to suit the needs of

the day. Therefore, to expect that whatever means Sushruta adopted in the treatment of a

case of skeletal injury nearly 3,000 years age would be as effective even today is

certainly not justifiable. The tremendous developments in all the fields of science and

technology have changed the entire picture of the situation. However, there are certain

principles behind every line of management, if correctly laid down, would universly

remain unchanged whatever be the means that may be adopted to achieve them. The

efficiency of Sushruta's skill regarding the management of a fracture case can be very

well put to test on this base.

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26

(2) Four Principles of Treatment

1) Anchana (Fig.- 13) 2) Peedana (Fig. 14)

3) Sankshepa (Fig .15) 4)Bandhana (Fig. 16)

(1) Anchana- Traction

(2) Peedana- Manipulation by local pressure.

(3) Sankshepa- Opposition and stabilization.

(4) Bandhana- Immobilization.

Sushruta has mentioned the principles of reducing a fracture, which is still

adopted today. According to him, surgeon should apply first traction from either side of

the fragments (Anchana), then elevate depressed fragments or depress the elevated

fragments (Peedana). The far displaced or overlapping fragments should be brought in

close contact with each other by manipulating them separately (Samkshepana). The fore

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27

going principles devote the efforts to achieve proper alignment of fractured fragments

before final immobilization (Bandhana).

Immobilization: An adequate immobilization of the fractured limb is one of the most

essential methods in the management, for this step usage of splints has been adequately

described by Sushruta. He has selected some important tree barks24 for this purpose. The

tree barks he has recommended are Ashwatha, (Ficus religiosa), Vamsha (Bambusa),

Kakubha (Terminalia Arjuna), Madhuka (Madhuka indica) Palasha (Butea monosperma),

Sala (Shovera robusta Gaertn.) Udumbara (Ficus Racemosa Linn.), Vata (Ficus

bengalensis),. Such splints were applied due to their availability without much difficulty.

Other aims of selecting these specific barks are

1) Barks were fit into the limb due to their concave inner surface.

2) Rigid and firm outer surface.

3) Inner surface being soft would act as the cushion to the limb there by avoiding

pressure sore.

(3) General treatment of Bhagna.

Sushruta instructs the surgeons before going to above steps he should follow the general

line of treatment i.e. 1) Pariseka 2) Lepana.

1) Pariseka : This means continuos sprinkling of the medicine in the liquid form e.g.

decoction, oil, ghee, etc. over the affected part for certain period of time. This

procedure induces analgesia and also causes dosha shamana. Different kinds of

Pariseka dravyas are described on the basis of Prakruti of the patient and season.

These are:

a) Nyagrodhadi decocation.: It is used in the patient of Pittika Prakruti and during

summer.

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28

b) Pancha mula Siddha dughda.: When fracture is in Vata pradhana Prakruti and

mainly suffering from pain, then Panchamula Siddha dugdha is preferred for Pariseka.

This preparation is also Pitta shamaka.

c) Chakra Taila: This is used in mainly vata and kapha prakruti persons and when

fracture has occurred in winter season and associated with severe pain. This

preparation is Ushna viryatmaka and reduces the pain and swelling at the fracture site.

2) Lepa: The local application at the affected part with medicinal paste or ointment is

called as the Lepa. Sushruta has described the Manjisthadi Lepa. It contains

Manjistha, Yastimadhu, Shalipisti, Raktachandana, and Shatadhautagritha. This lepa

reduces local pain and swelling. The ingredients get absorbed per cutenously and

helps bone healing.

After this the Anchana like procedures is to be followed. After completing the

general measures Aacharya has described the treatment part of various kinds of fractures

occurring in the each bone of the body.

(4) Specific Management for different types of fractures

In case of fracture associated with the wound or a compound fracture locally a

mixture of 'Nyagrodhadi gana dravyas' in paste form, Honey and Ghee should be

applied. Rest of management is as in case of general management.

In case of the phalanx fracture or dislocation, it should be first set in its natural

position and bandaged with pieces of thin linen and should be then sprinkled with ghee.

This ancient method resembles with modern management, in which the affected part is

supported by bandaging it along with a splint or neighbor finger.

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29

In case of Foot bone fracture the foot should be gently massaged with Ghee,

then duly splinted up, and then bandaged with linen. Such patient should forego all kinds

of movements.

In case of a fracture of Tibia - Fibula or Femur, the affected part should be

massaged with ghee and traction is carefully applied along the direction of the bone

carefully. after which it should be splinted with the barks and bandaged with the help of

linen. A case of fractured arm should be treated in the same manner.

In case of Hip joint dislocation reduction should be done by traction and

rotational movements then splint should be applied and bandaged in an appropriate

manner. In case of cracked or bruised femur fracture, the part should be bandaged in a

foresaid manner.

In case of Iliac fracture it should be reduced by manipulative procedures

including elevation of depressed fracture followed by bandaging the patient should be

treated with a sneha basthi.

Ancient Acharays in order to describe the poor prognosis of Katibhagna. They

have advised surgeons not to treat the same. Hence patients should be treated and

followed up very carefully by surgeon till the complete union of fractured bone .

In case of dislocation of Amasandhi (Shoulder joint.) the region of Kaksa

(Axilla) should be raised with an iron / wooden rod (Musala) then the surgeon should

bandage the part by Swastika Bandha ( Figure of Eight Bandage).

A dislocated Elbow joint first should be massaged with thumb, after which it

should be pressed with a view to set in its normal position alternating with flexion or

extension of the same. Then it should be sprinkled with any oleaginous substance. The

same measures should be adopted in case of dislocation of knee joint, wrist joint and

ankle joint.

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The fractured Metacarpal bones of the palm, the two palms should be made

even and opposed and bandaged together for support. In case of metacarpal bone fracture

of both the hands the splint should be applied to each palm for support. Then the affected

part is sprinkled with Taila.

In case of fracture of the Cervical spine causing lateral flexion or shortening of

the neck, a traction is applied in upward direction. Then around neck an appropriate

splint should be applied and tied with the help of linen. Then the patient is advised

complete bed rest in supine position for next seven days.

The Mandibular dislocation the region is fomented thoroughly then the

mandible is duly reduced its appropriate position and Panchangi Bandha is applied for

support. Gritha medicated with Madhura (Kakolyadi Gana) and Vataghana (Cavyadi

Gana) should be used for Nasya.

A Depressed Nose should be elevated with the help of the thin capillary rod

(Salaka) while it should be straightened in case of lateral displacement. Then two

hollow tubes should be inserted in to each nostril (to facilitate breathing) then nose is

bandaged and sprinkled with Gritha.

In case of Tered Ear Cartilage, Ghritha should be applied locally, then it

should be brought in to its natural position and bandage measures and remedial agents as

in the case of Sadhyo Vrana are adopted in the present instance.

In case of Frontal Bone Fracture which is not associated with any oozing out of

brain matter, it should be bandaged with local application of Honey and Gritha the patient

is advised to take only Gritha for further one week. In case of traumatic contusions the

surgeon should appliy the medicated pastes or ointments locally.

The Malunited Fractures to be re-fractured then it should be reduced properly

and treated in an appropriate manner.

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31

The Fractures occurring at the upper part of the body should be treated with

Sirobasthi, Karnapurana, Grithpana, and Nasya. The Fractures occurring at the

extremities should be treated with the Anuvasana Basthi.

In Old Dislocations the affected part is relaxed first by local lubrication of

oleaginous substances and hot fomentation. After achieving relaxation it should be

reduced with appropriate manipulative procedure.

Warning against Infection, A surgeon should exert his guard against the advent

of any Pyogenic infection setting in a fractured bone because of suppuration of local

muscles, vessels, and ligaments lead to poor prognosis of the fracture.

In case of Tibia, Fibula or Femur fracture Acharya have described the special

immobilization method, known as 'Kapata ShayanaVidhi'. In this method the patient

should be laid down on a plank or aboard and bound to five pegs or stakes in five

different places for the purpose of immobilization of affected limb. The distribution of

the pegs in each case should be as follows, in femur fracture a fair of peg should be

placed at either side of the hip joint and another pair should be placed at either side of the

knee joint and a peg should be placed at the sole. Thus it will cause immobilization of the

affected limb. In case of Tibia Fibula instead of putting pegs at the hip joint they should

be placed at the either side of the ankle joint. Rest of the pegs should be placed as

previous manner. The same procedure should be followed in case of fractures and

dislocations of pelvic joint , vertebral column, chest and shoulder joint.

The principle behind this procedure is the immobilization of the affected part

which is reduced properly. Acharays have the idea that the major fractures can not be

immobilized properly with the help of splints, also these bones require the

immobilization for longer period, hence they may have mentioned this procedure.

Rehabilitation: The importance of Physiotherapy in a limb injury was also appreciated

by Sushruta. He has prescribed the exercises starting in small doses, which may be

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32

gradually increased at any rate, and exercises should not be prescribed all at once in the

beginning. E.g. For rehabilitation of upper limb, in the beginning mud ball is held and

then a heavier substance like a lump of rock-salt and finally harder object like stones.

1) Mritapinda Dharana(Fig.17) 2) Lavana Dharana(Fig.18) 3)

PashanaDharana(Fig.19)

Along with all these measures ancient Acharya's have described numerous

medicinal preparations for the faster union of the fractured bone. These are chiefly

described as general tonics to provide liberal amount of proteins, fats, calcium and other

minerals. These Asthi Sandhaniya Dravyas not only hasten the bony union but also make

it strong they are also good for general health Some of the AsthiSandhniya Yogas

described in ancient texts are mentioned below.

THE LIST OF DRUGS IN THE MANAGEMENT OF FRACTURES

1. Gandha Taila 2. Gandhaprasarini Taila

3. Chakra Taila 4. BhagnasandhanaTaila

5. BhagnasandhanaVati 6. Laksha Guggulu

7. Lashunadi Vati 8. Ashwagandha Chaturbhadra choorna

9. Madhuyasthi Ksheerapaka 10. Pravala Panchamruta

11. Agarvadi Taila 12. Dhataki Lepa

13. Yastimadhu Taila 14. Sudha Bhasma

15. Rajata Bhasma

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Rejuvenators

1. Haritaki 2. Yastimadhu

3. Amalaki 4. Lashuna

5. Pippali 6. Kakoli, Ksheera Kakoli etc.

7. Shilajitu 8. Godhooma

9. Priyangu 10. Kapitha Phala Majja.

In addition to all these Acharya Sushruta advises to take the milk of Primiparous

Cow processed with gritha, drugs of Madhuragana. And Laksha daily during the morning

hours.

Pathypathya: A fracture patient must forego the use of Lavana, Katu Rasa, Kshara and

Alma articles of food and should live on strictest continence, avoid over exposure to sun

and forego physical exercises.

A diet consisting of Shali rice, meat soup, milk, ghee, soup of satina pulse and all

other nutritive and constructive food and drink, should be descriminately given to the

patient. As a general rule milk should not be prescribed to a patient suffering from Vrana

(Wound) in general, but a case of fracture forms an exception. There to some authorities

hold that the lukewarm milk may be given to the fracture patient, if there be no ulcer.

A case of fracture occurring in a youth or a person slightly deranged dosha or

(Alpadosa) or in winter season, is hailed to be easily curable with a help of aforesaid

methods. A fracture in youth gets healed in course of a month. In two months in a case of

middle aged man, and three months in the old aged man.

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CLINICAL SIGNS OF IDEALLY UNITED BONE

1) No swelling or hardness on palpation.

2) Absence of shortening and deformity.

3) Painless and easy movements

In such a detailed, scientific manner, ancient Acharays have described the condition of

Asthi Bhagna.

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35


The living thing is described by the general term as 'PROTOPLASM'. These

have many microscopic and submicroscopic structures. The smallest unit of protoplasm is

CELL, which has capacity of carrying out an independent existence. The Cell is the

structural and functional unit of living things. It is always seen in multicellular animals

that many cells of one kind constitute one kind of TISSUE. This tissue performs one

particular function. The human body composed of following elementary tissues:

1) Epithelial tissue.2) Connective tissue.3) Muscular tissue.4) Nervous tissue.

Osseous tissue or Bone: The framework of bones and cartilage that provides support,

protects our organs and allows us to move is called the skeletal system. Structurally, the

skeletal system consists of several types of connective tissue: cartilage, bone, red and

yellow bone marrow, the periosteum, and the endosteum. Bone tissues are connective

tissues that means that bone cells are scattered in the matrix, far apart from each others.

Bone cells lying in the matrix are enclosed in individual little chambers called lacunae.

Other types of bones cells are found on the bone membranes lining up the outer surface

of the bones as well as the bone cavities containing blood vessels and bone marrow.

Bone tissue is the one of the connective tissues. It is made up of the bone cells and

intercellular ground substance. The organic part of an Intercellular tissue is about 40%

and is composed of collagen fibers, bounded by mucopolysaccharide cementing material

called Ossein. The remaining 60% which are deposited as a dense substance are inorganic

mainly as calcium salt. Inorganic components that set it apart structurally and

functionally from all other tissues. Roughly, the matrix is about 20% water, 20% protein

and 60% mineral salts.

Inorganic Components: 1) They are mineral salts, mainly Hydroxyapatite (a

crystallized form of tricalcium phosphate), some calcium carbonate, and small amount

of magnesium hydroxide, flouride and sulfate. They give the bone its characteristic that




36

makes it unique among all the other tissues: an exceptional hardness which allows it to

resist compression. 2) Mineral salts are abundance: they make 65% of the bone mass and

nearly 2/3 of the matrix.

Organic Components: The organic component of the bone matrix is called osteoid.It

contains proteoglycans, glycoproteins and collagen fibers

Without the organic components of the matrix, the bone would be very brittle and it

would break if twisted or stretched. These organic molecules, especially the collagen

fibers act like reinforcing metal rods in concrete (the concrete here being the mineral

salts). They provide bone with great flexibility and tensile strength (resistance to being

stretch or torn apart).

Bone is covered with periosteum. There are four types of bone cells which are closely

related , those are

(1) Osteoprogenitors (2) Osteoblast (3) Osteocyte (4) Osteoclast.

Osteoprogenitors (Osteo =bone; pro = precursor; genitor = produce) :

FIG.20




37

They are in differentiated cells that will undergo mitosis and develop into

osteoblasts. They are found on the surfaces of bones and bone cavities containing blood

vessels and bone marrow.

Osteoblasts (Osteo =bone; blast = germ) :

These are found in growing surface where bony matrix is deposited. This cell

secretes the bone matrix and helps calcification. Because of its function of calcification,

bone forming possesses a rich enzyme, alkaline phosphate in the cytoplasm. They are

derived from Osteoprogenitor cells. Osteoblasts build bones: they are also found on the

surfaces of bones and bone cavities containing blood vessels and bone marrow. There,

they secrete the matrix. This is found in growing surface where bony matrix is

deposited.

Osteocytes (Osteo =bone; cyte = cell) :

These types of cells are trapped within the lacuna. These cells have got no active

synthesizing properties. They make the majority of the bone cells and are found

embedded in the bone matrix. Osteocytes derive from osteoblasts. Osteoblasts secrete

matrix, they surround themselves with the material and become "walled up" in the matrix

then, and they stop secreting matrix and become osteocytes. Osteocytes do not secrete

bone matrix: they only maintain the matrix surrounding them in good condition.

Osteoclasts (Osteo =bone; clast = destroy) :

This is a large bone cell found in the area where active reabsorption of bone takes

place. The cell is associated with the process of growth and remodeling bone. Probably it

secretes a proteolytic enzyme to dissolve bony tissue and its function is to reabsorb or

destroy the bone.

Classification of the bone : (I) Depending on the size, shape and distribution of the

cavities, the bone tissues will be categorized




38

(a) Compact or Ivory bone. (b) Cancelled or spongy bone.

By looking at the figures the two bony tissues can be identified

One that looks like Swiss cheese or like a sponge (the cheese stuff and sponge stuff being

the bone stuff): this is the spongy bone tissue. It is located inside bones. one that looks

denser, more compact: the compact bone. It makes the outer part of bones.

Compact bone tissue: (FIG.22)

C) Endosteum, D) Periosteum, E) Haversian canal,

I) Osteocytes J) Concentric lamellae, K) Interstitial lamellae,

L) Circumferential lamellae H)Osteon

The compact bone tissue made up of bone matrix deposited in layers 3-7 micrometers

thick.These layers of bone matrix are called lamellae (J, K, L).

The lamellae of compact bone are disposed in three different patterns:

FIG.21

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39

1. The concentric lamellae (J) are arranged concentrically around longitudinal vascular

channels to form the osteons (cylindrical units of the compact bone tissue H) they

have been coloured to differentiate them easily from the two other types of lamellae.

2. The interstitial lamellae (K) fill the spaces between osteons

3. The Circumferential lamellae (L) run around the circumference of the bone. The

inner circumferential lamellae are located on the inner side of the compact bone tissue

and the outer circumferential lamellae are located on the outside.

The bulk of the compact bone tissue is made of cylindrical units: the osteons (H). The

osteons are made of osteocytes (I) arranged in circles and concentric layers of bone

matrix (concentric lamellae J). The concentric lamellae are like tubes of different size.

Fitting inside each other to make an osteon. Running through the core of an osteons and

along its axis is the central canal (Haversian canal E) that contains blood vessels and

nerves.

Spongy bone tissue: This tissue does not contain osteons. It consists of layers of bone

matrix (lamellae) and thin plates of bone called trabeculae. The spaces within the

trabeculae are filled with red bone marrow and blood vessels connected to vessels of

haversian canal .

Periosteum: The periosteum (D) is lining of the outer surface of bones. It is made of a

tough outer fibrous layer (in black) and a thin inner osteogenic layer (in orange). The

fibrous layer (superficial layer) is made up of dense connective tissue fibers and

fibroblast with rich supply of blood vessels and lymphatic from which a good part of the

FIG.23

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40

nutrition of the bone is supplied. This later has got no osteogenic function and thus limits

bone growth.

Functions of Periosteum:

(1) It serves as tough fibrous covering and checks excessive bony growth. Normal bone

formation is controlled primarily by the periosteum. When due to injury or surgical

operation, it is torn off from the underlying bone, the liberated Osteoblasts start from

new bone at the site of injury and thus gives abnormal bone formation.

(2) Carries blood vessels.

(3) Affords attachment to the muscles and tendons.

Endosteum: It is lining the outside of the trabeculae and the wall of the Haversian and

Volkmann'canals. It is formed by condensation of the stroma of bone marrow. It contains

reticular cells.

Functions:

It possesses osteogenic and haemopoietic functions. Its activity takes part in the healing

of the fractures.

Bone marrow : The central marrow cavities of long bones and between the spicules of

latticework of spongy bones are filled with bone marrow. When the Osteoblasts invade

the cartilage model, marrow begins to form it. Yellow marrow is composed of mainly fat

cells or adipose tissue and is found in the marrow of cavity of long bones. Where as red

marrow is associated with the spongy bones, and contains certain amount of adipose

tissue and mostly blood forming tissue.

Functions:

(1) Production of blood cells and there release to circulation.

(2) Ethroclasia.

(3) Reticulo-endothelial functions.




41

(4) Osteogenic functions.

(5) Immunologic functions.

(6) General connective tissue functions.

Composition of Bone : 1) Water -25% 2) Solids- 75%

(A) Organic ( Mainly proteins) - 30%

Three proteins (a) Ossein- Asclero protein is the chief constituent.

(b) Osseomucoid- amucoprtein. (c) Osseo-albuminoid- a Keratin

(B) Inorganic-70%

The chief elements. calcium(Ca), Phosphorus (P), and Magnesium(Mg).

Potassium(K), Sodium(Na), and Chlorine (Cl),in small amounts, Iron(Fe),

Fluorine(F), Lithium (Li), and Strontium (Sr)- in traces.

Ca- remains mainly as phosphates and carbonates and slightly as chlorides and

fluorides Mg- is found mainly as phosphate.

(II) They can be classified on the basis of their shape and size

Bones are classified as :

1) Long bones, 2) Short bones, 3) Flat bones, 4) Irregular bones,

FIG.24




42

LONG BONES

Long bones are "long" their length is superior to their width. These bones consist of a

shaft (diaphysis) and two expanded ends (epiphysis, plural: epiphyses) that articulate

with other bones. The diaphysis has a thick wall made of compact tissue surrounding a

central cavity ( medullary cavity) containing yellow marrow (fat).

The epiphyses are covered by a thin layer of compact tissue. Their interior contains

spongy bones and red marrow. On its outer surface, the articular portion of the epiphysis

is coated with hyaline cartilage. Between epiphysis and diaphysis, there is the

epiphyseal line. This is a left over of the epiphyseal plate. The epiphyseal plate exists

only in young growing long bones and allows them to grow in length. The long bone is

entirely covered by the periosteum except where the articular cartilage coats the

epiphysis. The endosteum covers the surface of the medullary cavity, E.g.; Humerus,

Radius, Ulna,Etc.

FIG.25.




43

SHORT BONES

Short bones are "short", cube like and do not have any cavity similar to the medullary

cavity of the long bones. These bones are made mostly of spongy bone tissue, but their

outer parts are made of a thin crust of compact bone tissue.

Sesamoid bones are a special brand of short bones they are embedded within a tendon

and act to alter its direction of pull. They differ in size, and shape from an individual to

another. E.g. Talus, Calcaneum, Etc.

FLAT BONES

Flat bones are "flat", plate like. They are thin and do not have any cavity similar to the

medullary cavity of the long bones. The outer part of a flat bone is made of a layer of

spongy bone tissue sandwiched between two layers of compact bone tissue.

E.g. Scapula, Cranial bones, etc.

FIG.26

FIG.27

A & B

FIG.27

. B




44

IRREGULAR BONES

Irregular bones are all the weird-shaped bones that do not belong in any other category.

They do not have any cavity similar to the medullary cavity of the long bones. Irregular

bones are made mostly of spongy bone tissue enclosed by a thin crust of compact bone

tissue E.g. vertebra.

FUNCTIONS OF BONE

1. Support : It does the skeletal support and shape to the body.

2. Assist in movement : It forms a leverage system for movement.

3. Protection :It affords protection to the vital organs like brain, etc.

4. Blood cells production : Bone marrow does formation of blood cells.

5. Mineral homeostasis : The bone cells help in maintains of the body's electrolyte

balance i.e. the distribution of calcium , phosphate ions.

6. Energy storage: It is a great reservoir of minerals, for the blood.

7. Detoxification: Bone eliminates toxins such as lead, fluorine, etc.

8. Attachment: It gives attachments of muscles, and tendons.

9. Reticuloendothelial cell: It is a chief site for reticuloendhothelial cell.

10.Assistence to other systems : It assists different systems e.g. in forming nasal cavity

for respiratory system and beginning of the digestive system in forming mouth.

COLLES’ FRACTURE

FIG.28




45

Colles’ fractures are very common extra-articular fractures of the distal radius

that occur as the result of a fall onto an out stretched hand. They consist of a fracture of

the distal radial metaphyseal region with dorsal angulation and impaction, but without

involvement of the articular surface.

Etymology

Originally named by Abraham Colles (1773-1843) Irish surgeon, Dublin.

Epidemiology

Colles’ fractures are the most common type of distal radial fracture and are seen in all

adult age groups and demographics. They are particularly common in patients with

osteoporosis and as such, they are most frequently seen in elderly women. The

relationship between Colles’ fractures and osteoporosis is strong enough that when an

older male patient presents with a Colles’ fracture, he should be investigated

for osteoporosis because his risk of a hip fracture is also elevated.

Younger patients who sustain Colles’ fractures have usually been involved in high impact

trauma or have fallen, e.g. contact sports, skiing, horse riding.

Mechanism

Most Colles’ fractures are secondary to a fall on an outstretched hand with a pronated

forearm in dorsiflexion (the position one adopts when trying to break a forward fall). The

proximal row of the carpus (particularly the lunate and scaphoid) transfer energy to the

distal radius, both in the dorsal direction and along the long axis of the radius. Most

fractures are therefore dorsally angulated and impacted.

Radiographic features

A number of classification systems exist for distal forearm fractures. One of the more

popular is the Frykman classification system, although it fails to distinguish between

Smith and Colles’ fractures as it is based on AP radiographs. As such, in clinical practice,

the use of the term Colles’ fracture with an appropriate description of any associated

injuries is sufficient in most instances.

http://radiopaedia.org/articles/distal-radial-fracture

http://radiopaedia.org/articles/osteoporosis

http://radiopaedia.org/articles/fall-onto-an-outstretched-hand

http://radiopaedia.org/articles/lunate

http://radiopaedia.org/articles/scaphoid

http://radiopaedia.org/articles/missing?article%5Btitle%5D=frykman-classification-system




46

Plain films usually suffice, although if there is concern of intra-articular extension then

CT may be beneficial.

Plain film

AP and lateral wrist x-rays usually suffice. The fracture appears extra articular, and

usually proximal to the radioulnar joint. Dorsal angulation of the distal fracture fragment

is present to a variable degree (as opposed to volar angulation of a Smith fracture). There

is also usually impaction with resultant shortening of the radius. An associated ulnar

styloid fracture is present in up to 50% of cases.

Treatment and prognosis

The vast majority of Colles’ fractures can be treated with closed reduction and

cast immobilisation. The cast extends from below the elbow to the metacarpal heads and

holds the wrist somewhat flexed and in ulnar deviation. Open reduction and internal

fixation should be considered when the fracture is unstable, and/or unsatisfactory closed

reduction is achieved (e.g. >10 degrees dorsal angulation; >5 mm shortening; significant

comminution).

Complications include :

• malunion resulting in dinner fork deformity

• median nerve palsy and post traumatic carpal tunnel syndrome

• reflex sympathetic dystrophy

• secondary osteoarthritis, more frequently seen in patients with intra-articular

involvement

• EPL tendon tear

http://radiopaedia.org/articles/smith-fracture

http://radiopaedia.org/articles/missing?article%5Btitle%5D=ulnar-styloid-fracture

http://radiopaedia.org/articles/missing?article%5Btitle%5D=ulnar-styloid-fracture

http://radiopaedia.org/articles/dinner-fork-deformity

http://radiopaedia.org/articles/missing?article%5Btitle%5D=median-nerve-palsy

http://radiopaedia.org/articles/carpal-tunnel-syndrome-1

http://radiopaedia.org/articles/complex-regional-pain-syndrome

http://radiopaedia.org/articles/missing?article%5Btitle%5D=secondary-osteoarthritis

http://radiopaedia.org/articles/missing?article%5Btitle%5D=epl-tendon-tear

DRUG REVIEW



47

DRUG REVIEW

''……. I often say that when you can measure what you are speaking about and

express it in numbers. You know some thing about it' but when you cannot measure it ,

when you cannot express it in numbers. Your knowledge is of a meager and

unsatisfactory kind; it may be the beginning of the knowledge, but you have scarily, in

your thoughts, advanced to the stage of science what ever the matter may be…….."

-------------- LORD KELVIN

There are large numbers of medicinal preparations mentioned by acharya

Sushruta in for the management of bone injuries. In the present study the medicaments

mentioned by Sushruta in his treatise Sushruta Samhita Chikitsa Sthana 3rd chapter is

evaluated. Where he mentions the Lepa, for external application over fracture site

followed by bandhana for immobilization with plant barks. For internal administration he

indicates Ksheerapaka. The ingredients of these preparations are as follows.

1) Lepa : Manjishta (Rubia cordfolia), Yashtimadhu (Glycyrhzia glabra),

Raktachandana (Santalum rubrum), ShaliPishti (Oryza sativa), Shatadhauta Gritha

(hundred times processed Ghee).

2) Ksheerapaka : Grishta Ksheera (Primy cow's milk), Sarpi (Ghee), Laksha (Lacciferus

lecca), Madhura gana Dravya's( Kakolyadi gana Dravya's).

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48

DRUGS USED FOR LEPA

MANJISTHA

(FIG.56)

Lat. Name : Rubia cordifolia, Linn, R.manjista, R. secunda.

Sans,Mah.& Kan - Manjista, Chitravalli. Eng Indian Madder, Dyer's Madder.

Morphology - This is a climbing plant growing in the north- Himalayas, Pushpakala -

Sharata Rutu. Phala kala - Shishir Rutu. Useful part - Root.

Guna & Karma :

Rasa: Madhura, Tikata, Kashya. Guna : Guru , Ruksha.

Veerya: Ushana. Vipaka: Katu. Doshagnata - Kapha-Pitta shamaka.

Karmas : Varnya, Swarya, Vishghna, Raktashodaka, Mootra visarjaniya,

Bahaya Karma: Shotahara, Vrana Ropana, & Kushtagna,

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49

Constituents - Roots contain resinous matter, gum, sugar, coloring matter and salts of

lime. Coloring matter consists of a red crystalline principle - purpurin a yellow principle

glucoside -Manjistin, garancin, alizarin ( orange- red) and xanthine ( yellow)

Action -Plant root was considered emmenogogue, astringent and diuretic.

Uses - Dried root was much used in dropsy, paralysis, jaundice, amenorroea and visceral

obstructions. The decoction , tinges the blood, urine and even the bones, red. A paste

made by rubbing up the roots with honey is a valuable application for freckles and other

discoloration of the skin; also in external inflammations, ulcers and skin diseases.

YASHTI MADHU

(FIG.57 a) (FIG.57 b) (FIG.57 c)

Family: Leguminacea. Latin name: Glycyrrhiza glabra

Synonyms: Sans: Kleetaka,Madhuka. Hind: Mulethi, Eng: Sweetwood,

Habitat: Arabia, Persia,Asia- minor and in Punjab, Sub - Himalayan tracts.

Habit: It’s an herb of 2-4 ft. height. Leaflets small, Flowers- violet coloured.

Chemical constituents: Root is having whitish, sweet factor - Glycyrrhizin 5-10%

present. In this Glycyrrhizin acid, potassium and salts are present. Sugar- 5-10%, Starch-

30% Fats, Gum, Asparagin- 1%.

Guna-Karma :

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50

Guna:Guru,Snigdha, Rasa: Madhura, Tikta, Veerya: Sheeta, Vipaka: Madhura

Karma: Snehana,Balya, Vrishya, Rasayana, Shothahara, Vranaropaka.

Dosha-karma: Kapha shamaka, Pitta-shamaka, Vata-shamaka.

In Sushrutha, in ' Sarvopaghata shamaniya' yoga this drug is included. So in all types of

Abhighata this can be given. Along with the ghritha, yastimadhu kalka prayoga is done

over Vrana.

Dosage: Moola Churna- 1-4 masha.

SHALI

(FIG.58 a) (FIG.58 b)

Family: Gramineae. Latin name: Oryza sativa.

Synonyms: Sans: Shali, Hindi: Chaval, Eng: Rice,

Habit: It’s an aquatic, annual herb. Stem is cylindrical and yellowish.

Shali types : Bhavaprakash--Shali are of 4 types.

1)Shali (Hemanth rutu- Phala pakwa) 2) Rakta - Shali.3)Vrihi (A year crop). 4)

Shashtika - Shali (60 days crop).

Part used: Grain, Spirit and vinegar.

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51

Chemical constituents: Rice contains more starch, small amount of fat, proteins and a

trace of mineral matter. Of the total protein 5 p.c. present in rice globulin is 0.14,

Albumin 0.04 and the remainder is just like a protein Glutenin.

Guna-Karma: Guna: Laghu ,Snigdha. Rasa: Madhura, Kashaya.

Veerya: Sheeta Vipaka: Madhura.

Dosha karma: Vata - Pitta Prashamana. Alpa kaphakara.

Action: Balya, Ruchya, Swarya, Vrishya, Brimhana, Mootrala,

Uses: Poultice of the rice with curd from which excess of water is removed applied

comfortably hot, four times a day gives ample relief in abscesses, by diminishing its pain

and burning sensation; by diminishing the thickness of the base. The rice poultice

requires changing twice or even thrice daily. It is an excellent application to abscesses,

boils, ulcers and other local inflammatory affections.

SHATADHOUTA-GRITHA

(FIG.59 a) (FIG.59 b)

Ingredients: Goghrita.

Method of preparation: Pure cows ghee taken in big bronze plate, and cold water

should be poured above the level of ghee. It should be rubbed vigorously for a few

minutes. When the water becomes slightly warm, it is replaced by a fresh cold water.

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52

This method is repeated for 100 times. Such a processed ghee is called "Shatadhouta

ghritha".

Water pouring will modify the properties & effects of the ghritha. However ghritha is

laghu, but in a short amount of time, it is disintegrated & assimilated by virtue of 100

times washing, at certain height 3 feet a sterile cool water poured over ghee. Because of

this ghritha attains readily the absorbability, either by internal or by external application.

Both these aggreability presumed both at the mucosa of G.I.T. & at the cellular level. So

this preparation is introduced into the text mostly for an acute conditions where tissue

repairs is needed. So it can be indicated in Bhagna, Urahakshata, Dagdha Vrana,

Netrabhishyanda, Arbuda etc…

Guna-Karma: Guna: Laghu, Snigdha. Rasa: Shadrasa.

Veerya: Sheeta. Vipaka: Madhura.

Doshakarma: Pitta-Vata hara

Karma: Deepana, Rasayana, Deerghamayusyakaram.

RAKTA CHANDANA

(FIG.60 a) (FIG.60 b)

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53

Family: Fabacea ( Leguminacea) Latin name: Pterocarpus santalinus.

Synonyms: Sans: Raktanga, Lohita, Raktasara, Ranjana, Shonita

Habitat: Its natural habitat of dry hills of southern India.

Habit: It’s a tree of 5-10 Mt. Height. Bark-blackish gray coloured, on deep cut a reddish

coloured liquid oozes out.

Heart wood: Grayish outside, blackish red inside. Fruits: 6-9cmslong

Part used: Heart wood - Santalum rubrum ( Kashta), Oil-( Taila)

Constituents: Santalin or Santalic acid, a crystalline red principle; Santal pterocarpin, a

white crystalline insoluble substance; homoterocarpin with the same general properties,

but more soluble in carbon bisulphide; glucoside and coloring matter.

Guna-Karma :

Rasa: Tikta, Madhura. Guna: Guru, Ruksha, and Sheeta.

Veerya: Sheeta. Vipaka: Katu.

Dosha karma: Pittahara, Pitta-Kapha shamaka.

Actions: Dahaprashamaka, Jwaraghna, Rakta-Pitta shamaka, and Shothahara,

Dosage: Kashata churna: 1-2gms,Kandasara churna: 2-5 gms.

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54

DRUGS USED FOR KSHEERAPAKA

GHRISHTA-KSHEERA

(FIG.61)

Sans -Dugdha,Ksheera. Eng -Milk. Arab-Halib.Pers-Sher. Kan- Haalu.

Sources-Mammary glands of females, cows, she-goats,ewes, etc.

Characters - It’s a collagein type of milk, in each milk collagein occurs either an alkali

or acid. When joins with the natural milk collagein out of milk is exposed or time lapsed

milk also gets fermented and which epicts the collagein part of the milk is said otherwise

as grishta-ksheera. Collagein is a calcium in structure. It supports in making any layer or

wet substances may be in the form of lepam or paste, induces hardness this property of

grishta-ksheera helps in the ossification of injured bone internally and when applied

externally supports the casting material to get hardness.

As in this study due to rare availability of collagein milk (grishta-ksheera) the

cows milk is used for the purpose. Hence its characters are mentioned as below:

Constituents.- Milk contains all the elements necessary for the growth and nutrition of

bones, nerves, muscles and other tissue. Milk contains also vitamins which are Nature's

antidotes to rickets, scurvy. It contains a large proportion of calcium phosphates an

important salt required for the formation of bone and also for the proper

coagulibility of the blood.

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55

LAKSHA

(FIG. 62a) (FIG. 62b)

San.- Laksha Eng.- Lac, Shellac, Hind., Mah. & Kon. - Lakh, Ben - Gala.

Mal. - Lakasha. Kan.- Aragu ; Laksha Tam - Kombarakku ; Araku.

Source:- Lac is resinous substance usually reddish or dark brown in colour. Deposited

on the twigs of the trees such as Banyan, acacia and peepu, by small insect called

''Carteria Lacca''.

Regarding the formation of Lacca there are different opinions. Some state that insects

attack the young branches of the trees above mentioned and fix themselves to the

branches; the female insect after oviposition dies, giving out her body a reddish liquid

which solidifies and forms a crust about an inch thick round the branch attacked; others

again affirm that the sting of the insect affects the sap or gum of the trees, which forms

the lac. Another opines that the deposit is an excreta of the insect Tacchicardia lacca.

Guna Karma: Rasa- Kashaya Veerya - Sheeta Vipaka- Katu

Doshaghnata- Pitta- Kaphaharam Guna- Snigdha,

This is a drug of choice in bone healing. Lac is a specific application in dental caries and

diseased teeth. Lakshadi taila is used as an in unction in several diseases. The fine

powder of Laksha is mixed with honey and given in haematemesis. Lac is specific

DRUG REVIEW



56

application for caries and disease teeth. Madhura gana dravya's: Sushruta has

mentioned Kakolyadi gana Dravya's and few other drugs under this heading.

Kakolyadi gana dravyas: Kakoli, Ksheera kakoli, Jeevaka, Rishabhaka, Mudgaparni,

Mashaparni, Meda, Mahameda, Chinnaruha, Karkatakashringi, Tugaksheeri, Padmaka,

Prapundarika, Riddhi, Ruddhi, Mrudwika, Jivanti, Madhuka.

Milk, Ghee, Vasa (Muscle fat), Majja (marrow), Shashitika Shali,Yava (Barely),

Godhuma, Masha, Shringataka (Trapa bispinosa),Kasheruka (Scirpus kysoor), Trapusha

(Cucumis sativus), Ervaruka (Cucumis utilissimus), Karkaruka (Cucumis melo), Alabu

(Lagenaria vulgaris), Kalinda (water melon), Kataka (Strychnous potatorum),

Gilodya, Piyaala (Buchananialanzan.spreng),Pushakara bija, Kashmari, Madhuka,

Draksha,Kharjura, Rajaadana, Taala(Barassus flabelliformis), Narikela( Cocus nucifera),

Ikshu vikara(Products of sugarcane), Bala (Sida cordifolia), Atibala, Vidari,

Payasya(Vidari bheda), Goksuraka, Ksheeramorata, Madhulika (Glycyrhizza glabra),

Kushmanda.

Madhura Rasa Guna:

Veerya: Sheetha. Vipaka: Madhura.

Dosha-Karmata: Pitta-Vata shamaka & Kapha vardhaka.

Madhura Rasa gives the happiness, Does the Dharana of Sharira, rasadi all

Dhatu's are increased with Upadhatu's. Good for eyes, hairs, complexion, strength, Which

does the union of two break ends, Rakta and Rasa prasadaka, Gives comfort in Baala,

Vriddha, Injured/weak- debilitated persons, reduces thirst, Moorcha, Burning sensation.

All the indrias including Manas are nourished.

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57

Drugs Used for LEPA (Table No 5)

Drugs Rasa Guna Veerya Vipaka

Manjistha Kashaya, Guru Ushna Katu.

Tikta Ruksha

Yesthimadhu Madhura Guru Sheeta Madhura

Raktachandana Madhura Guru Sheeta. Katu

Shalipisti Madhura Snigda Sheeta Madhura

Kashaya

Drugs Used for Prakshepa in KSHEERAPAKA (Table No 6)

Laksha Kashaya Snigdha Anushna Katu

Laghu

Ghrita Madhura Guru Sheeta Madhura

MATERIALS & METHODS


WITH LAKSHAKSHEERA AND MANJISTADI LEPA 55 58

MATERIALS AND METHODS

The present clinical study was aimed to assess the efficacy of the Laksha

ksheera and Manjistadi Lepa on management of Bahir Prokoshtasth bhagna (Colles’

Fracture).

Study design- An open clinical trial was undertaken on 30 patients.

Source of data:

30 Patients of Colles’ Fracture were selected randomly from the Surgical out patient and

in patient Dept. of Shalya Tantra, T.M.A.E. Society’s Ayurvedic Medical

College,Hosepet.

Inclusion criteria

1. Stable Colles’ fractures

2. Both Male and Female patients

3. Patients with simple (closed) Colles’ fracture)

4. Patient’s age group between 15 to 60 years.

Exclusion criteria

1. Open radius fractures

2. Patients with nerve and vessel injury

3. Patient suffering with any other debilitating diseases

4. Infective diseases of the bone like osteomyelitis

5. Patients of deficiency diseases.

Diagnostic criteria

1. The clinical features like History of trauma, Pain and swelling in the affected

forearm.

2. Positive findings of Colles’ fracture radiographically.

MATERIALS & METHODS



Requirements

• Bamboo splints

• Steel vessels

• Roller gauze

• Gauze pads

• Gas stove

• Gloves

• Cotton roll

Fig. 10 Drugs used for Lepa

Manjista

Raktha chandana

Yasti madhu

Shali pisti

Shata dhauta gritha

Drugs used for Kseeerapaka:

Yastimadhu-10 grams

Kshira - 100 ml

Jala -800 ml

Ksheerapaka of madhura dravya (yashtimadhu) was prepared in the manner of

Ksheerapaka preparation method. 10 gm each of laksha choorna and ghee was added to

the prepared ksheera. This was given100ml internally daily in the morning.

The following drugs were taken in equal quantity and lepa was prepared and applied

to the affected part.

MATERIALS & METHODS



Intervention:

Selected patients were examined as per the clinical proforma prepared for

the study and subjected to routine blood and urine examinations to rule out other systemic

disorders.

The selected patients were subjected to parisheka of laghupanchamoola

ksheera paka. This was followed by Realignment of the fractured ends by reduction

techniques of conventional closed methods by shake hand method as in Colle’s fracture.

After reduction, Manjistadi lepa was applied. To maintain this reduced

position, splints prepared out of bamboo sticks covered with cotton roll were placed in

position with roller gauge kept in collar sling. Laksha ksheera was given internally.

The bandha was changed once in week without disturbing the fracture alignments.

This treatment was continued for 6 weeks.

After confirming the bony union clinically, active physiotherapy like

initially mrtpinda dharana, lavana pinda dharana and pashana dharana was followed in

successive days. The patients were advised to take with restrictions of lavana, katu and

amla rasa, kshara and ruksha dravyas. Advised to avoid atyadhika maithuna, atapa sevana

and vyayama.

MATERIALS & METHODS



Fig. 12: Sushruta’s Procedure

Follow up study –

Patients were examined on initial day zero and further followed up weekly and

the changes of signs and symptoms in the patients were recorded weekly once based on

the research proforma like

1. Subjective improvements

2. Objective improvements

Subjective improvements: The improvement in the clinical symptoms of the disease

was assessed based on the gradation of each symptom as follows.

The Clinical gradations of symptoms are as follows

1) Pain: No pain-00

Tolerable pain - 01

Intolerable pain - 02

Parisheka Alepa

Bandhana Kusha Bandhana

MATERIALS & METHODS



Fig.13: RADIOGRAPH SHOWING HEALING OF BONE

2) Swelling: No swelling -00

At site-01

At related joint-02

At whole limb-03

3) Tenderness: No tenderness-00

Patient winces-01

Patient winces and withdraws affected part-02

Patient does not allows to touch the part-03

X-ray, 0 day X-ray, 7th day

X-ray 21st day

MATERIALS & METHODS



4) Loss of function: Normal function-00

Able to perform with difficulty-01

Unable to perform-02

5) Callus assessment: Good callus - 00

Mild callus - 01

No callus - 02

Objective improvement – To assess the objective improvements, radiographic

examination carried out before the initiations of treatment then weekly till the clinical

union of the fracture.

OBSERVATION & RESULTS



55 64

OBSERVATIONS

The clinical trial was conducted on 30 patients. The observations and results made are as

follows.

A) Age wise distribution of patients- (Table No – 7)

Sr.no Age group No of patients Percentage

1 21-30 06 20%

2 31-40 13 43%

3 41-50 07 24%

4 51-60 04 13%

Total 30 100%

Out of 30 patients youngest patient age was 21 years and eldest patient was 58years of

age.

B) Sex wise distribution of patients-(Table no-8)

Sr no Sex No of patients Percentage

1 Female 21 70%

2 Male 09 30%

Total 30 100%




55 65

After analyzing the data related to sex 21 patients were female and 09 patients are male.

C) Distribution of patients on the basis of their Economical status- (Table no-9)

Sr. no Socioeconomic

status

No of patients Percentage

1. Lower class 15 50%

2. Middle class 12 40%

3. Upper class 03 10%

Total 30 100%

0

2

4

6

8

10

12

14

16

Lower class

Middle class

Upper class

After analysis the socioeconomic status of 30 patients found that 15 patients were from

low socioeconomic status, 12 patients of middle class and only 03 patients of upper class.

0

5

10

15

20

25

Female

Male




55 66

D) Occupation wise distribution of patients- (Table no-10)

Sr no Occupation No of patients Percentage

1 House worker 12 40%

2 Labour 09 30%

3 Job holder 06 20%

4 Students 03 10%

Total 30 100%

0

2

4

6

8

10

12

House Worker

Labour

Job holder

Stuents

After analyzing the occupation data it was found that maximum patients were house

worker.

E) Distribution of patients on the basis of locality. (Table no-11)

Sr no Locality No of patients Percentage

1 Rural 18 60%

2 Urban 12 40%

Total 30 100%

0

5

10

15

20

Rural

Urban




55 67

Cases were analyzed in view of their habitat, out of 30 patients 18 patients were reported

from rural area and 12 patients from urban area.

F) Incidence of patients as per their prakruthi. (Table no-12)

Sr no Prakruthi No of patients Percentage

1. Vata-pitta 15 50%

2. Pitta-kapha 9 30%

3. Vata-kapha 6 20%

0

2

4

6

8

10

12

14

16

Vata-pitta

Pitta-kapha

Vata-kapha

After analyzing the data related to prakruthi it was found that maximum i.e. 9 patients

were reported as vata-pitta prakruthi.

G) Incidence rate of mode of injury: (Table no-13)

Sr no Type of injury No of patients Percentage

1 Road traffic

accidents

09 30%

2 Domestic fall 15 50%

3 Hit 03 10%

4 Fighting 03 10%

Total 30 100%




55 68

Incidence rate of mode of injury Among 20 patients was about 50% by domestic fall.

H) Incidence rate of Side of involvement of (dominant or non dominant) hand.

(Table no-14)

Sr no Involved Side No of patients Percentage

1 Right side 24 80%

2 Left side 06 20%

Total 30 100%

In 80% of patient’s right side hand was found to be involved more dominant.

0

5

10

15

20

25

Right

Left

0

5

10

15

R TA

Domestic fall

Hit

Fighting




55 69

Results

1. Effect of therapy on Pain: (Table no-16)

Pain Mean

score

Mean

difference

% Of

improvement

S.D S.E t-Value p-value

BT 1.85

Ist Week 0.75 0.8 44.7% 0.647 0.137 5.7 <0.001

IInd Week 0.7 1.17 66.7% 0.517 0.109 10.08 <0.001

IVth Week 0.26 1.4 88% 0.512 0.114 13.27 <0.001

VIth Week 0.14 1.6 93.4% 0.504 0.112 15.48 <0.001

2. Effect of therapy on swelling (Table no-17)

Swelling Mean

score

Mean

difference

% Of

improvement


BT 1.25

Ist Week 0.45 0.8 64% 0.41 0.092 8.72 <0.001

IInd Week 0.4 0.85 68% 0.58 0.13 6.48 <0.001

IVth Week 0.2 1.05 84% 0.601 0.135 7.77 <0.001

VIth Week 0.05 1.2 96% 0.695 0.155 7.74 <0.001

3. Effect of therapy on Tenderness (Table no-18)

Tenderness Mean

score

Mean

difference

% Of

improvement


BT 1.5

I Week 0.95 0.55 36.6% 0.51 0.12 4.82 <0.001

II Week 0.35 1.15 76.6% 0.59 0.13 8.70 <0.001

IV Week 0.15 1.35 90% 0.75 0.17 8.13 <0.001

VI Week 0.05 1.45

96% 0.83 0.18 7.88 <0.001




55 70

4. Effect of therapy on loss of function (Table no-19)

Lossof

function

Mean

score

Mean

difference

% Of

improvement


BT 1.1

I Week 0.75 0.35 31.8% 0.49 0.11 3.21 <0.001

II Week 0.35 0.75 68% 0.44 0.09 7.58 <0.001

IV Week 0.20 0.9 81% 0.45 0.10 9.0 <0.001

VI Week 0.1 1.0 90% 0.46 0.10 9.8 <0.001

5. Effect of therapy on callus (Table no-20)

Callus Mean

score

Mean

difference

% Of

improvement

S.D S.E t-

Value

p-

value

BT 2

I Week 2 0 0 0 0 0

II Week 1.8 0.25 12.5% 0.44 0.09 2.52 <0.05

IV Week 0.8 1.20 60% 0.52 0.13 10.34 <0.001

VI Week 0.45 1.65 82.50% 0.49 0.11 15.08 <0.001

Table No - 21 Showing the statistical analysis of symptoms after treatment.

Sr.no Symptoms Mean

score

% Of

improvement

S.D S.E t-Value p value

1 Pain 0.15 91.4% 0.502 0.112 14.28 <0.001

2 Swelling 0.05 96% 0.695 0.155 7.74 <0.001

3 Tender ness 0.05 96% 0.83 0.18 7.88 <0.001

4 Loss of

function

0.10 90% 0.46 0.10 9.8 <0.001

5 Callus 0.45 82.50% 0.49 0.11 15.08 <0.001




55 71

Table No-22 Showing the statistical analysis of symptoms

before and after treatment.

Sr no Symptoms BT AT

1 Pain 1.75 0.15

2 Swelling 1.25 0.05

3 Tender ness 1.5 0.05

4 Loss of function 1.1 0.10

5 Callus 2 0.45

0

0.5

1

1.5

2

Pain

Swelling

Tenderness

Loss of

functionCallus

DISCUSSION



72

DISCUSSION

"It is too bad that we cannot cut the patient in half in order to compare two régimes of

treatment" --- Bela Shick.

01) Bahir Prakoshtasthi Bhagna is a troublesome disease.

Bahir Prakoshtasthi Bhagna is a condition where the suffering patients are generally

immobilised for a period of one month up to six months, which naturally affects their

physical, social, economical as well as psychological status of life. Due to increasing

faster competitive lifestyle, the incidence of trauma is increasing day by day.

02) Focus on modern management.

There is an established modern line of treatment for fracture, though showing

good results in the management and prognosis, it is time consuming. The orthopedic

branch of modern science has grown very well since last few decades. New methods of

fracture treatments are being introduced day by day. The main intention of these new

modern techniques is to make affected bone in to normal bone both by structurally as

well as functionally. Also the intention is to reduce the time consumption for

immobilisation. The modern science has succeeded in this part after invention of modern

techniques like open reduction along with internal fixation. This type of treatment has

given good results in major, compound, comminuted and complicated fractures. But the

management of fracture patient with a help of open reduction and internal fixation carries

a great amount of risk of infection. Modern science has not found out any oral

preparation those which will enhance bone healing. For simple fractures the management

recommended is application of POP as a cast and a splint for achievement of total

immobilisation of fractured bone. This application of Plaster Of Paris has got many

hazards like, nerve compression, compartmental syndrome and muscle wasting etc. and

DISCUSSION



73

the Plaster of Paris has no role in bone healing. Hence in these conditions to check the

efficacy of Sushruta's technique, certain Ayurvedic preparation being tried.

What so ever the advanced means and methods attained so far, the basic

principles are similar to Ayurvedic methods. The body physiology and pathology are

primly considered in fracture management apart from fracture treatment by ancient

scholars. The modern science upholds the fact that only the approximation is not the sole

treatment in the fractures but there are certain other factors which are responsible for

union of fractures such as hormones, vitamins, minerals, etc. Acharya Sushruta has

primly mentioned about such facts and his Technique of management of Asthibhagna.

03) Sushruta's technique of management

Acharya Sushruta has described different steps for fracture management, for early

healing of fracture and strengthening it. The same being tried in the present study.

Sushruta has indicated a LEPA for application over fracture site and administration of

Ksheerapaka internally for proper union of fractured bone. The LEPA consists of

Manjistha, Yastimadhu, Shatadouta gritha, Raktachandana and Shalipishiti. The

ingredients of Ksheerapaka are Yastimadhu, Ksheera, and Laksha. These are available in

all parts of India and they are harmless and cheapest preparation, even for low

economical groups. These preparations can be administered on OPD basis does not

require any hospitalization.

04) Theoretical co-relation of Ayurveda and Modern literature.

a) Aetiology: The main cause for fracture is trauma which is mentioned in both

Ayurveda and Modern literature. In olden days the common causes for fractures were

Fall, Compression, blow, etc. such types of Trauma's will usually exerts much force

which usually results with fracture bone. Hence even today these etiological factors will

cause the fracture.

DISCUSSION



74

b) Symptomatology: The signs and symptoms which are mentioned by Sushruta are

Swelling, Tenderness, Crepitus, Loss of function, Different types of pain and Inability

to find comfort in any position. These general features mentioned by him are just the

same as are written in any standard modern orthopedic surgical text book. In other

words what Sushruta wrote several centuries ago with a meager facilities of carrying

clinical investigations is as a principle so thorough and perfect that it hardly had room

to permit any alteration.

c) Prognosis: Sushruta has mentioned prognosis of fractured patient depends on

1) General condition, health and age of the patient.

2) The type of fracture and the bone involved.

These detailed descriptions of prognosis are so specific and fundamental inspire of

tremendous progress in Orthopedic branch of surgery most of its parts has remained

unchanged. The prognosis of fracture mentioned by Sushruta is yet identical with

that mentioned in Modern Orthopedic text.

d) Management: It is true that the methods of management of fractures have now been

modified greatly over a period of nearly 3000 years but the fact cannot be denied that

the principles of fracture management laid down by Sushruta still hold good and

deserve appreciation. The fundamental principles which Sushruta mentioned are

Anchana, Pidana, Sankshepana, and Bandhana which are identical with the

fundamental treatment of fracture described by Modern Orthopedic science. These

principles of orthopedic surgery speak for the perfection achieved in those days.

Acharya Sushruta has described treatment part of fracture in such a detailed manner

that most of its basic parts are yet to be used with a great success and its use will be

continued in future also.

DISCUSSION



75

e) Warning against infection: Whatever be the management of bone injury the

primary duty of a surgeon is to see no infection takes place at the injured site. He

should make every possible effort to avoid contamination and infection. Once the

bone infection sets in, it is a difficult job to manage the case and life of the patient

becomes miserable. Sushruta had known this fact and therefore he has strongly

recommended the adaptation of measures that would avoid suppuration.

f) Rehabilitation: The importance of physiotherapy in a limb injury was practiced by

Acharya Sushruta. Sushruta has prescribed the exercises in this regard like, lifting of

lighter objects in beginning e.g.: mud-ball, and then heavier substances like a lump of

rock-salt, and finally still harder objects like stones. This would avoid sudden jerking

at freshly healed region and would permit better union by improving circulation.

Sushruta's contribution also includes indication of special devices like fracture

bed, treatment of protruding bone fragments, treatment of malunited bones, treatment

of injured tooth and finally he gives certain criteria of ideally united bone and what a

surgeon is to expect in a case of ideally healed fracture. Those are:

i) Absence of gap between broken fragments ii) Absence of shortening iii) Absence

of deformity iv) Return of painless and easy movements.

All these signs are exactly similar to those signs described in Modern Orthopedic

texts to assess clinical bony union. In short ancient acharya have described the disease

fracture in such a detailed specific and cautious manner that it is referred successfully

in these days of modernization.

05) Role of trauma as nidana:

The etiology of fracture in this trial it is observed is due to trauma, which is

commonest etiological factor for fracture. Trauma caused due to vehicular accidents, due

to fall, assault injuries reported more in this study.

DISCUSSION



76

06) Role of X-ray :

After clinical diagnosis of fracture, X-ray investigation was performed to confirm

it. The X-ray enables a surgeon to know about type of fracture, Plain of fracture,

Displacements of fracture in terms of shift, Angulation, Shortening, Rotation and

distraction.

Acharya Sushruta has given elaborate idea about such types of diagnosis that is,

he has mentioned the effect of trauma on bones involved and particular type of fracture at

particular site. E.g.: Cartilage's bend, The long bones break, Flat bones cracks, Small

bones fragmented. Today we are able to examine an injured bone directly under

radiological examination, but in the absence of these methods, Sushruta evolved this

useful and most logical method of determining the type of fracture.

07) Classification of Bhagna.

Sushruta has classified the skeletal injuries in to two groups according to their

therapeutical importance that is Savrana and Avrana Bhagna. This is a broad type of

classification of skeletal injuries but in the management it plays an important role. Even

in Modern orthopedic text books we find this type of classification that is simple and

compound fractures.

Sushruta had very clear idea about difference between fracture and dislocation,

Hence in the beginning only he has classified the skeletal injuries into two broad groups

namely (a) Injuries of skeletal origin involving joints (b) Skeletal injuries proper. The

same he has further classified in to six types of dislocations and twelve types of fractures.

Such type of classification covers the classification seen in modern orthopedic text books.

The twelve varieties of fracture classification and their nearest modern synonyms are

mentioned in literature review.

DISCUSSION



77

The very fact that he was able to diagnose the particular variety without the help of

Roentgen rays (which were not discovered in those days ) Only from the direction of a

force causing fracture and the deformity at the site caused by muscular components is

suggestive of his keen clinical sense and the power of logical imagination. The important

point to note in this classification is that, it not only includes the varieties of fractures

known today, but it also carries some minute observations like periosteal avulsion and is

therefore more complete and superior to modern classification of fractures. In fact

Sushruta has viewed fractures as "bone injuries" in the true sense and not merely as

discontinuity of bony surface. This speaks for his deep understanding and capacity of

recognizing the facts without altering their originality.

8) Chikitsa: Sushruta’s principles of fracture management still holds good, it is true that

the methods of management of fractures have now been modified greatly over a period of

nearly 3000 years but the fact cannot be denied and deserves appreciation. The

fundamental principles laid down by Sushruta are Anchana, Pidana, Sankshepana, and

Bandana, which are identical with the fundamental treatment of fractures in

Orthopaedics. These principles of orthopaedic surgery speak for the perfection achieved

in those days. Acharya Sushruta has described treatment part of fracture in such a

detailed manner that most of its basic parts are yet to be used with a great success.

Whatever is the management of bone injury the primary duty of a surgeon is to see no

infection takes place at the injured site, he should make every possible effort to avoid

contamination and infection. Once the bone infection sets in, it is a difficult job to

manage the case and life of the patient becomes miserable. Sushruta was known this fact

and hence he has strongly recommended the adaptation of measures that would avoid

suppuration.

DISCUSSION



78

9) Rehabilitation: Acharya substrata advised the patients to perform different exercises

in a limb injury. like, lifting of lighter objects in beginning e.g. mud-ball, and then

heavier substances like a lump of rock salt, and finally still harder objects like stones.

This would avoid sudden jerking at freshly healed region and would permit better union

by improving circulation.

Sushruta's contribution also includes indication of special devices like fracture

bed, treatment of protruding bone fragments, treatment of malunited bones, treatment of

injured tooth and finally he gives certain criteria of ideally united bone and what a

surgeon is to expect in a case of ideally healed fracture. Those are:

i) Absence of gap between broken fragments

ii) Absence of shortening

iii) Absence of deformity

iv) Return of painless and easy movements.

All these signs are exactly similar to those signs described in Modern Orthopedic

texts to assess clinical bony union. In short ancient acharya have described the disease

fracture in such a detailed specific and cautious manner that it is referred successfully

in these days of modernization.

10) Discussion on materials and methods

In present days the bhagna Chikitsa is not widely in use though it was practiced and used

more than 3000 years with great success. But there are some problems in adopting this

line of treatment. May be due to lack of qualified persons, lack of exposure, fear to

manage, the advanced management techniques of modern science etc. But being all this

Ayurvedic line of management for fractures is still alive in rural areas; certain folklore

practitioners are using these skills and managing the cases successfully. Considering

these facts and also to assess the efficacy of Sushruta's technique scientifically taking

radius as an individual bone this present study was carried out. Before this there were few

works carried out ingenerally, But most of them tried partially, to check the efficacy of

DISCUSSION



79

different Ayurvedic formulations, which are recommended for fracture healing. But in

present study it is taken in total, the principles and drugs been put on for research to

check their efficacy. In this study 30 patients of Colle’s fractures were taken and they

were managed with Ayurvedic management i.e. after Parisheka, Anchana, Peedana,

Sankshepanadi kriyas, the fractured limb was immobilized with application of Lepa and

by using bomboo splints. Internally the patient was given Laksha Ksheerapaka.

11) Discussion on observations and results

A) The study revealed that the incidence of Bhagna was commonly seen in the

age group of 31-40 years i.e. 43%. Mostly this may be due to this age group patients are

young adults and are more labour group by which, they happen to be sustain more

trauma.

B) The sex incidence shows there was 70% of patient’s females also do the hard works

like men. This May be the reason why female patients were more in number the fractures

are limited to a particular community or more prevalent in one aspect as they generally

distribute among the people and the community plays no part in it.

C) The economical status wise incidence shows that, there was more number of patients

reported from lower class i.e 50%. Here it may be due to strenuous work, poor and

vitamin deficient food of lower class people are reported more. May be they drive more

or they are more in number but these all facts do not have to play any role in fracture

incidence.

D) The locality wise incidence shows that more number of patients from rural area i.e.

60%. This may be due to the rural people do more laborious works otherwise there is no

special cause why the rural patients are reported more.

DISCUSSION



80

E) The Prakruti wise incidence indicates, there were more patients from Vata-Pitta

Prakruti i.e. 50%. This may be because Vata Prakruti people are more active also may be

because these people may have more fragile bones. This may be the reason why these

group patients were reported more.

12) Signs and symptoms

The most commonly observed signs in fractured patients were swelling and pain.

To assess these signs and symptoms they are graded as per their characters. As the aim of

clinical study is to assess the efficacy of Ayurvedic management of Radius as individual

bone. Pain and swelling are important symptoms of this fracture. In this study neither a

single anti inflammatory nor analgesic drug was used. The initial mean value of pain was

1.75, and then it was reduced to 0.15,Usually this pain was relieved to the patients

immediately after parisheka But in most of the patients after one week of observation it

came down drastically. Hence these observations indicate the parisheka with

laghupanchamoola ksheerapaka has got analgesic action.

The observations towards swelling also show that there was drastic reduction of swelling

after application of lepa for 2 or 3 sittings. The initial mean value was 1.25, which was

reduced to 0.05 after the application of Lepa. The same indicates the efficacy of lepa in

reducing the swelling. That means this lepa has got definite role to play with anti-

inflammatory action.

As callus formation is the part of fracture healing, the patient, tissue, and treatment

variables influence it. Subsequently, these factors can influence the time of appearance of

callus in the radiograph. The age is one of the important variables that influence fracture

healing. This may be related to the increased vascularity and ability of the cells of

periosteum to differentiate in younger individuals. Certain tissue variables can also affect

the development of callus formation. Radiographic evidence of callus is dependent on

site of bone involved, as well as the nature of fracture. Fractures, particularly in the

DISCUSSION



81

diaphyseal region develop more callus than metaphyseal fractures. The difference is

related to the amount of periosteum enveloping the bone. In these cases, clinical

parameters, such as lack of pain with movement or tenderness on palpation, are used to

assess fracture healing. This is also true for impacted fractures. As in this study the age

group 20-60 patients are taken, the number of patients with radius lower end fractures are

more, hence callus assessment was difficult. But in these cases direct diaphysis involved,

in these cases the same is assessed properly and callus formation was early in these cases.

The P value is < 0.001 this statistical analysis shows that the treatment is effective in

reliving the symptoms like pain, swelling, tenderness and loss of function.

In few patients early callus formation was observed that this might be due to the

effect of Ksheerapaka. Still more researches need to be carried out to assess the same.

13) Discussion on probable mode of Action of Drugs

Parisheka: In this study the action of trial preparation like parisheka, lepa and

ksheerapaka of the drugs explained on the basis of their Rasa, Guna, Veerya and Vipaka.

In kandabhagna, vedana and shotha are the two dominant features, so for parisheka, laghu

pancha mula ksheerapaka is the right choice.

The vedana / arthi/ruja are because of vata this can be known through a quotation

by sushruta ‘Na arthi aniladhrugam’. When all dravys of laghu pancha moolas are

evaluated for its properties it can explained that out of five drugs three are having

vatahara gunas (snigdha), three are having vata hara rasa (madhura), four are having

vatahara virya(unsha) and three are having vatahara vipaka(madhura) and also these

drugs mainly indicated in ‘vatoottara shula’ condition as these drugs processed with

ksheera which is again vatahara . So totally this combination is vatagna in nature

DISCUSSION



82

In charaka samhita sutrastana 4th chapter mahakashaya vargas are mentioned. Among that

shotagna mahakashaya includes laghupancha moola dravys , so shotagna action of this

laghupancha moola dravys can be considerd without any question . Totally with pariseka

of laghupancha moola dravys, kandabhagna with vedhana and shotha can be managed

effectively.

Sushurta in chikista 3rd chapter mentioned the laghupancha moola’s in the bhagna

condition when shula and shota are present in pitta prakruthi, and ushna kala for

sandhanaartha, pakapariharatha and vedhana pariharatha. In case of vatoottara shula also

the same combination mentioned works better.

Sushruta in shareera 9th chapter explained tiryagatha dhaminis functions like

‘gavakshi’, the tiryagatha dhaminis sira mukha’s present in roma kupas, so the

parishrka stimulates Brajaka pitta, and absorbes, there by paka occurs, thus shota and

shula are reduced. The samprapti shows the involvement of raktha and vata, where rakta

causing avaraana to vata. Thus the parisheka relives the avaraana and subsides the pain

and swelling.

For each patient this procedure was done for five minutes in one sitting about four angula

in height (Ref-Takradhara atsangahrudaya sutra.)

Lepa: Almost in all the patients the swelling was reduced within 24-36 hours after

application of the lepa. This may be because; the lepa consists of following drugs,

Manjistha

Manjistha by its action it is raktaprasadaka and as it is having Ushna Veerya due

to which it will dilate the peripheral vessels, especially there will be venous dilatation

followed by increased peripheral arterial blood flow. This may be the reason for the

reduction of the swelling around fracture area. As it is having kapha-pitta-shamaka

property by which it will reduce the local edematous residue and its ushna veerya

property helps to penetrate in to local tissue. The chemical composition is calcium salts,

DISCUSSION



83

gum, resinous matter may be absorbed, by these properties it initiates for early callus

formation.

The swelling is the one of the reason for pain at fracture site due to pressure on peripheral

sensory nerves. Where in here the reduction of the swelling and pain may be due to its

ushna property and madhura rasa by which local vata shamana action takes place and

pain is reduced.

Yashtimadhu

This drug is told in Sandhaneeya gana by charaka, and with madhura and kashaya

rasas, it definitely enhances the bone healing. As this drug is having Madhura and

Snigdha properties due to which it reduces the Pitta i.e. it does anti-inflammatory action

locally. And also this drug, which is having the property of Madhura Vipaka and guru

guna due to which it, does vata shamana i.e. responsible for shoolahara. As it is having

anti-microbial properties by which it doesn't allow to grow any microbes in the lepa and

its chemical composition includes salts and potassium, these may also help for bone

growth when it is absorbed internally.

Shatadouta ghritha The Laghu Guna of gritha enhances, after it has been washed

hundred times. Means it attains much Laghutva by its sanskara and becomes readily

permeable in to skin by body temperature. As the molecules of ghrita and further

reducedwhich is now rendered easily into the skin. The Snigdha and Madhura property

of the same reduces swelling and pain. The Snigdha guna may also enhance the bone

formation at fractured site. The fatty lobules of the absorbed ghritha may help for tissue

repair as in case of fractures.

Raktachandana Due to its Madhura Rasa and Sheeta Veerya it reduces Sthanika daha

by which it helps to reduce pain. By shotahara property of this drug it will take out the

edematous fluid of fractured site.

DISCUSSION



84

Shalipisti The Laghu Guna makes the drug penetrate through skin very easily. The pisti

prepared out of it will be having Pichhila guna, at the time the Sheeta Veerya and

Snigdha property of the drug creates stickiness on the skin by which it puts a local

pressure which makes the collected tissue fluid to escape out. The same drug may again

absorb this. The starch content of the Shali gives strong support to fractured bone. Hence

this may be very important drug in reducing swelling, pain and for immobilisation.

Ksheerapaka It consists of highly active principles of drugs like Yashtimadhu, Laksha,

and ghritha. As Yashtimadhu is balya and dhatuvardhaka, raktastambaka, pittashamaka,

by these properties, administered internally, initially it may act as anti-inflammatory.

Then due to its other properties like madhura rasa,madhura vipaka and sandhaneeya guna

definitely it plays a major role in early callus formation.

The study, which was carried out at Banaras Hindu University by Dr. P. J.

Deshpande on "effect of Shell-lac in healing of fracture." Where they did an animal

experiment and it was a chemical and histological study. The results says that the Laksha

when administered orally in milk basis acts beneficial in fracture healing by influencing

cellular organization and activity in the repair phenomena. The mucopolysacchride

contents sharply raised in the first week, soon followed by study rise in the collagen

content of the treated bones. This suggests the collagenization phase starts much earlier

than the control series. The good amount of proteins supplied through the milk could also

contribute to better healing of fracture of the treated animals. There is fibroblastic

proliferation mainly in the first and second week and Osteoblastic proliferation in the

third and fourth week. Although the cellular activities continue throughout the period of

healing, the maximum activities seen in the period mentioned above. Apart from the

histological evidence the bio-chemical observations suggest increased collagen content of

the treated bone tissue in the first and subsequent weeks.

In the third and fourth week the histological studies are also well supported by the bio-

chemical observations. During this period chondroblasts, which are rapidly multiplying,

DISCUSSION



85

penetrate in the region of collagen fibers and are followed by proliferating Osteoblasts.

All this phenomena especially Osteoblastic proliferation and Osteochondral ossification

seems to be stimulated in the animals receiving this drug. However, the stimulation is not

as pronounced as other known anabolic hormones like dianabol, testosterone etc.

Similarly in the fourth and fifth week the remodeling process also takes place more

rapidly than the control animals. This all indicates that the drug may probably be having

some anabolic activity, which produces general retention of nitrogen and minerals

leading to the positive nitrogen balance.

Thus the researches have proven that the Laksha has got definite role in forming

Osteoblastic cells at fractured bone. The Grishtaksheera (collestrum milk) that has got

rich proteins, calcium and other minerals. Hence by virtue of these properties it helps in

early bone healing by nourishing the injured bone.

Splints

The barks of several trees were advised for splintage. But in present study the splints

prepared out of bamboo were used due to its easy availability. These splints can be made

as per the size required; the limbs can exactly fit in to the inner concave surface of the

bark. The outer surface of the bark being rigid gives adequate support for broken limbs,

but the disadvantage observed that, if it is not properly rolled by cloth it may rub against

the skin and create wounds. As Sushruta has named few drugs for ideal splintage and the

drugs are having similar properties like Ruksha, Kashaya, Sheeta, Mrudu these may have

definitely to do something with fracture healing. A further study is required in this regard.

14) Discussion on Results

From this study it was found that pain,swelling,tenderness and loss of function

was very effectively reduced within one week of treatment,which is stastically proved

with p-value <0.001.This may be attributed to the treatment modalityadopted.The callus

DISCUSSION



86

formation in the present study was started early by the end of 2nd week.This shows that,

the present treatment stimulated the callus formation at an earlystage to fascilitate early

bone healing.

CONCLUSION


WITH LAKSHAKSHEERA AND MANJISTADI LEPA 87

CONCLUSION

Based on the analysis and observations made in this clinical study the following conclusions

can be drawn.

1. This is an open clinical trial done on 30 patients.

2. Colle’s Fractures continue to most common skeletal injuries treated by Orthopaedic

Surgeons.

3. Acharya Sushruta’s principles confidently implemented in this study.

4. The fractures were reported more from labour class and female patients.

5. Most of the cases were reported due to domestic fall, vehicle accident, are chief cause of

fracture was reported.

6. The two important factors like pain and swelling before and after treatment are with mean

value of 1.75 to 0.15, 1.25 to 0.05respictively with statistically highly significant.

7. Administration of Laksha Ksheerapaka is effective in early bone healing

8. In this study bamboo splints were used to maintain reduction in position.

9. This procedure is safe, easily available, less complications, and better acceptability.

10. Thus management with manjishtadi lepam and laksha ksheeram is found effective in the

management of Bahir prakoshtasthi bhagna

11. The null hypothesis is rejected and alternate hypothesis is accepted.

SCOPE FOR FURTHER STUDY

1. Further wide range of study is to be needed to say authoritatively whether the lepa and

parisheka have any added advantages, separately with the help of bio-chemical analysis.

2. Ksheerapaka may be administered along with internal fixations in compound fractures, its

efficacy can be made out.

3. The same technique can be tried in the cases like delayed union or non-union.

The bio-chemical, Histological studies to be carried out to assess the efficacyof

ksheerpaka in enhancing bone healing.

SUMMARY



SUMMARY

The title of the dissertation is

“Management of Bahir Prakoshtasthi Bhagna (Colle’s Fracture) with Lakshaksheera and

Manjistadhi Lepa.

The study confined only to Colle’s fractures.Described the fracture from the

therotical, practical and clinical point of view in a systematic way.

Acharya Sushruta than Charaka extensively deals the concept of fractures and its

management. And the later authors like Vagbhata, Bhavapraksha, Yogaratnakara etc.

have followed Sushruta’s aspects of classification and nomenclature of fractures.

The introduction consists of incidences of fractures and the importance of

Ayurvedic management of fractures and need of current study.

Then the next chapter deals with Ayurvedic literature review. This includes

Rachana and kriya shareera of Asthi, Asthi dhatu karma, classifications of Bhagna, its

management, possible complications and post healed fracture maintainance.In this the

photo clips of four principles of Sushruta’stechniques are shown.

A chapter follows this on Modern literature review where bone anatomy is dealt

in detail with Radius and its applied aspects then followed by the causes for fractures,

mechanism of fractures, different types of fractures, management, and concept of fracture

healing.

Then the next chapter deals with Drug review, where in the drugs, which are used

for fracture management as per Sushruta Samhita is discussed in detail. Then the

materials and methods followed in the present study were mentioned in detail with

evidence of Radiographs of callus formation are shown.

Under the chapter observations and results, the observations made out during the

study were explained with the help of graphs and tables.

The next part includes discussion and conclusion where the observations made

out during the study, the literature review and about materials and methods adopted and

results discussed in detail.

BIBILIOGRAPHY

BIBLIOGRAPHY



1. A.D. Shastri, Susruta Samhita, Part I-II, Chaukhambha Samskrita Sansthana, Varanasi, 11th edn,

1997

2. Amarasimha, Amarakosha, Chaukhambha Sanskrit Sansthan, 3rd edn, 1968

3. B.G. Ghanekar, Susruta Samhita, Meharchand Lachmandas Pub.,New Delhi, Reprint-2006

4. Dale M Daniel, Wayne H Akeson, John Joseph O’Connor, Knee ligaments : Structure, function,

injury and repair, Raven Press, New York, 1990

5. Dr. J.L.N. Sastry, Dravyaguna vijnana, Chaukhambha Orientalia, Varanasi, 3rd edn, 2008

6. Dr. K. M. Nadkarni, Indian Materia Medica,volume one, Popular Prakashan Private Limited,

Mumbai, 3rd edition,2009

7. H.P. Vaidya, Ashtanga Hrdaya with Sarvangasundari and Ayurvedarasayana treaty, Chaukhambha

Orientalia, Varanasi, 9th edn, 2005

8. Hariprasad Pandey, Bhavaprakash vidyotini tika, Chaukhambha Sanskrit Samsthan, 6th edn, 1997

9. Harsh Mohan, Textbook of pathology, Jaypee brothers, New Delhi, 5th edn, 2006

10. http://wikipedia.org

11. http://www.biosearch.in

12. http://www.ncbi.nlm.nih.gov

13. John Ebnezar, Textbook of orthopaedics, JAYPEE Brothers Medical Publishers (P)Ltd, New Delhi,

4th edition,2010.

14. K. Ramachandran Reddy, Bhaishajya kalpana vijnanam, Chaukhambha Sanskrit Bhavan, Varanasi,

1st edn, 1998

15. K.D. Tripathi, Essentials of medical pharmacology, Jaypee Brothers Medical Publishers (P) Ltd, 6th

edn, 2010

16. K.L. Bhishagratna, Susruta Samhita, Part II, Chaukhambha Sanskrit Series Office, Varanasi, 4th

edition, 1991

http://wikipedia.org/

http://www.biosearch.in/

http://www.ncbi.nlm.nih.gov/

BIBILIOGRAPHY

BIBLIOGRAPHY



17. K.M. Nadkarni, Indian Materia Medica, Bombay Popular Prakashan, Mumbai, 3rd edn, 1994

18. K.N.Shastri, G.N.Chaturvedi, Caraka Samhita, Part I-II, Chaukhambha Bharati Academy, Varanasi,

2002

19. K.R. Kirtikar, B.D. Basu, Indian Medicinal Plants, Int. Book distributors, Dehradun, 3rd edn, 1991

20. K.R. Srikantha Murthy, Astanga Sangraha, Chaukhambha Orientalia, Varanasi, 9th edn, 2005

21. K.R. Srikantha Murthy, Bhavaprakasa of Bhavamisra, Chaukhambha Krishnadas Academy,

Varanasi, 2008

22. N.S. Williams, C.J.K. Bulstrode, P.R. O’Connell, Bailey & Love’s Short Practice of Surgery,

Edward Arnold Publishers Ltd, 25th edn, 2008

23. P.K. Warrier, V.P.K. Nambiar, P.K.C. Ramankutty, Indian Medicinal Plants, Aryavaidyasala, Orient

Longman Pvt. Ltd., Chennai, 1994

24. P.V. Sharma, Dravyaguna vijnana, 2nd volume, Chaukhambha Bharati Academy, Varanasi, 2001

25. P.V. Sharma, Susruta Samhita, Part I-II, Chaukhambha Viswabharati, Varanasi, 2005

26. R. Remadevi, Bhaishajyakalpana, Perfect Publications, Kottakkal, 2004

27. Raja Radhakantadev Bahadur, Shabdakalpadruma, Chaukhambha Ayurveda Pratisthana, 2006

28. Robert Hannon Fitzgerald, Herbert Kaufer, Arthur L Malkani, Orthopaedics, Elsevier Health

Sciences, 2002

29. Ronald McRae, Clinical Orthopaedic Examination, Elsevier Limited, 6th edn, 2010

30. S. Das, A concise textbook of surgery, Calcutta, 3rd edn, 2006

31. S. Das, A manual on clinical surgery, Calcutta, 6th edn, 2004

32. S. Poddar, Handbook of osteology, Scientific book company, Ashok Rajpath, 11th edn, 2003

33. Sabiston, Textbook of Surgery, Elsevier Saunders, Philadelphia, 17th edn, 2004

34. Sailaja Srivastav, Sarngadhara Samhita, Chaukhambha Orientalia, Varanasi, 2nd edn, 1998

BIBILIOGRAPHY

BIBLIOGRAPHY



35. Vd. Yadavji Trivikramji Acharya, Susruta Samhita with Nibandha Sangraha, Chaukhambha

Orientalia, Varanasi, 1997

36. Watson-Jones Fractures and Joint Injuries, edited by J.N. Wilson, B.I. Churchill Livingstone Pvt.

Ltd, New Delhi, 1st edn, 1992

37. William C Whiting, Ronald F Zernicke, Biomechanics of musculoskeletal injury, Human Kinetics,

2nd edition, 2008

ANNEXURE



92

T.M.A.E. Society’s Ayurvedic Medical College

Department of P.G.Studies in ShalyaTantra

Case sheet

Title: “Management of BahirPrakoshtasthiBhagna (Colles’Fracture) with

Lakshaksheera and ManjistadiLepa”

Name of scholar: Dr Vijith V Nangelil

Guide: Dr Manonmani L M.D (Shalya)

Co- Guide Dr Radha B.K M.S (Ayu)

Reg. No. Hospital No.

Age : Sex :

Name :

Religion : D.O.A :

Address : D.O.D :

1. HISTORY OF PRESENT ILLNESS &DURATION :

Mechanism of injury ;

Patana / Peedana / Praharana / Akshepana / VyalamrugadaSana

2. SITE OF INJURY :

Upper limb - a) Fore Arm Radius

Ulna

Radius & Ulna

3. TYPE OF FRACTURE :

1. Displaced 2.Undisplaced

ANNEXURE



92

2. FRACTURE LINE :

1. Transverse 3.Oblique

2. Spiral 4. Hair line

5. HISTORY OF PAST ILLNESS:

6. H/O PREVIOUS BONE DISORDERS & TREATMENT IF ANY:

7. ADDITIONAL DATA:

1. Occupation

2. Socioeconomic status – lower / middle / upper

3. Inhabitance – Rural / Urban

4. Habit- Alcohol / Tobacco / Drugs / Any other

5. Diet – Veg / Non veg

8. DATA RELATING TO FRACTURE:

1. Extension of swelling: only at the fracture site / related

joint / whole limb

2. Presence of Crepitus

3. Loss of function

4. Pain

5. Tenderness

6.In ability to find comfort in any position

9. GENERAL EXAMINATION:

Pulse: BP: Temp: Wt:

Prakruti: V / P / K, VP / PK / KV, & VPK

Sara: Rasa / Rakta / Mamsa / Meda / Asthi / Majja / Shukra / Satva

Samhanana: Pravara / Madhyama / Avara

Satva: Pravara / Madhyama / Avara

ANNEXURE



92

Satmya: Pravara / Madhyama / Aavra

Vyayama :Pravra / Madhyma / Avara

Pramana :Pravara / Madhyama / Avara

10. SYSTEMIC EXAMINATIONS:

CVS:

CNS:

RS:

PA:

11. INVESTIGATIONS:

Blood; Hb% TC ESR DC

Urine:

Rdiological findings:

12. VYADHI VINISCHAYA:

13. MANAGEMENT: PARISHEKA - Lagupanchamoolaksheerapaka.

BHAGNA-STHAPANA

ALEPA - Manjistadilepa

BANDHANA

INTERNALLY -Lakshadiksheerapaka.

14. FOLLOW UP: (in days)

ANNEXURE



92

PERFOMANCE

STATUS

1st 7th 14th 21st 28th 42nd 56th

Swelling

Tenderness

Loss of function

Pain

Radiological findings

15. RESULT:

Signature of the Scholar Signature of the Co-Guide Signature of the Guide

By Dissertation Submitted to the Rajiv Gandhi University Of ...

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