Use of Ayurveda and Sri Lankan traditional medicine for healing shaft of humerus fracture following nonunion.

Sri Lanka comprises of a well-established traditional orthopedic treatment system. A 14 year old child had a compound fracture over shaft of humerus. The internal fixator Kirschner (k) wire was applied following allopathic treatment and after three weeks, it was removed as there was no healing of wound over fracture site. Patient was asked to follow orthopedic clinic but defaulted and presented to Ayurveda management. X-ray reports showed nonunion of the humerus. Initially, nonunion bone was immobilized for six months using bamboo splints. Prior to applying the splints, during every visit, herbal oil and herbal paste were applied. Subsequently up to six months, motor, sensory functions assessment and quality of life (QoL) assessment was done using Quality of Life of the International Osteoporosis Foundation (QLIOF) questionnaire. Initial power of wrist and fingers were graded 1 and in 6- months time, improved to grade 5. The difference in the QLIOF scores were analyzed using Wilcoxon signed rank test. There was a significant (p = 0.03) difference between the pre-treatment (14) and post-treatment (59) QLIOF scores. The anterior- posterior and lateral X-ray showed complete healing of the fracture. This report indicates that the methods and medicines in Ayurveda and traditional orthopedic system can successfully treat a nonunion of humerus fracture.

Introduction

Bone reduction, immobilization and rehabilitation are the basic principles of fracture management. Immobilization is useful to prevent displacement or angulation of the broken fragments [1]. Further, prevention of movements relieves the pain and enhances the healing. In modern medicine, permanent modes of immobilization are application of: plaster of Paris cast; continuous traction; external fixation and internal fixation [2]. Nonunion is a serious complication of a fracture and thus warrants surgical management to remove the scar tissues between bone fragments and immobilization with a mode of fixation.

Ayurvedic medical system has a long history and the school of surgery is qualified with a vast array of methods for fracture treatment. From the past, it has been overlapped with native orthopedic methods which are practiced in Sri Lanka. Currently, traditional orthopedic medicine is popular among laymen as an effective treatment modality. Most of the treatments used by native practitioners were verbally transmitted and sometimes written in palm-leaf manuscripts of which one common book was published in 1893 as Handi Veda Pota (treating fractured joints) [3]. In traditional medicine, various preparations like pattu, mallum, and oils are commonly used as external applications for fracture healing. In addition, internal medicines like decoctions, gruels, pills and powders are used in management of other symptoms and complications during the treatment.

According to Ayurveda, multiple types of fractures are described at the shaft of bones and are termed as Kanda Bhagna [4]. Twelve types of Kanda Bhagna are described in Susruta Samhita. The fracture was classified according to local symptoms and it's shape. In our case, shaft of humerus seemed to be Ashwakarna Bhagna (fracture appearing like the ear of a horse) and according to the International Classification of Diseases (ICD-10), shaft of humerus fracture is classified under S42.3. The shaft of humerus fracture is common among middle aged and over one-third population. The aim of this study was to identify the fracture healing effect of Ayurveda treatment combined with the traditional orthopedic medical system after nonunion of a fracture.

Case report

A 14 year old male had a compound fracture over the shaft of the humerus and presented to Ayurveda treatment following failure of allopathic treatment. During the allopathic treatment which lasted for over two months, the mode of internal fixation, the Kirschner (k) wire, was applied and in three-weeks time it was removed while asking to follow the orthopedic clinic. Patient was having a discharging wound with features of inflammation over fracture site suggesting bone and soft tissue infection. The reason for removal of k wire at the orthopedic treatment unit was planned due to acute osteomyelitis. The patient was having wasted forearm associated with restricted movements of arm including elbow, wrist and fingers. The X-ray showed nonunion of humerus. Physical examination revealed difficulty in adduction, abduction, flexion and extension of upper arm and the power was 1/5. Pain, edema, local tenderness and stiffness over wrist joint and fingers were observed at the initiation of the Ayurvedic treatment.

Diagnosis

Diagnosis was done according to the evidence of radio imaging (X-ray) and inflammatory markers (ESR- 114 mm/first hour and CRP-76 mg/L) as having nonunion following acute osteomyelitis. The radio imaging, motor, sensory function and quality of life (QoL) assessment were sequentially done to monitor the progress of fracture healing. The difference in the QoL scores, sign and symptoms were analyzed using Wilcoxon signed rank test. Statistical software of SAS 9.1 version (USA) was used for the study [5].

Treatment

First treatment regimen (day 1–60)

During the first two months, external application of 120 ml of Seetodaka oil [6], [7] was carried out every other day and Bamboo splints were applied in the lateral and medial position of elbow to shoulder joint [7]. During the entire treatment of six months, splints were kept in lateral side and medial side of the humerus from elbow joint to shoulder joint. Bandaging was done moderately every other day while external herbal applications were applied to the fractured area for over the six months period.

Second treatment regimen (day 61–120)

Following 2 months of above treatment, 30 ml of Pinda oil [6] with 30 g of Katakaladi paste applied was applied with bamboo splints and the patient was asked to perform passive and active exercises.

Third treatment regimen (day 121–180)

During the last two months, 30 ml of Narayana oil with 30 g of paste of Ashwaganda was applied with bamboo splints. Patient was asked to do the active exercises.

Preparation of drugs

Oil of Seethodaka was prepared according to the classical text of Ayurveda Pharmacopeia [6] and oils of Pinda and Narayana were prepared according to the methods given in the classical text Bhaishajya Ratnavali [8]. Preparation of paste of Katakaladi and paste of Ashwagandada were done according to the methods mentioned by the eminent Sri Lankan traditional physician “Arangala Veda Parapura”.

Preparation of paste of Katakaladi

240 ml of juice was extracted from the bark of Bridelia retusa (Katakala), Syzygium cumini (Jambu) and Hemidesmus indicus (Shariva) and powder of rhizomes of Zingiber officinale (Shunti), fruits of Piper longum (Pippali), stem of Coscinium fenestratum (Daruharidra), pericarp of Terminalia chebula (Abhaya), pericarp of Terminalia bellerica (Vibhithaka) and pericarp of Phyllanthus embillica (Dhathri) were added to it and heated until a semi-solid paste was obtained.

Preparation of paste of Ashwagandada

60 gms of powdered Withania sominifera (Ashwagandha), 30 gms of powdered Vigno mungo (Masha), 15 gms of powdered Cinnamomum zeylanicam (Thwak) and 15 gms of powdered Syzygium aromaticam (Lavanga) were grinded with 120 ml of egg white and mixed with 60 ml of bee honey to form a semi-solid paste.

Treatment outcomes

Sequential x-ray images

Sequential x-ray images from before, during and after completion of treatment are given in Fig. 1.

Fig. 1

a: Before treatment; b: at 45 days (callus formation indicates red circle); c: at 90 days (partial remolding indicates red circle) and d: after completion of treatment at 150 days (complete remolding indicates red circle).

Motor function assessment and follow up

Motor function assessment (upper arm) was done initially following the commencement of treatment and during the treatment. Power of flexion, extension, adduction and abduction moments was graded as 1 in upper arm. After 20 weeks of treatment, it improved to the normal level (Grade 5).

Sensory function assessment and follow up

Sensory functions including sensation of pain, temperature, vibration and fine touch was intact at commencement and throughout the treatment.

Assessment of QoL

QoL was assessed before the treatment and at 1, 2, 4 and 6 months of treatment (Table 1) using the Quality of Life of the International Osteoporosis Foundation (QLIOF) wrist fracture questionnaire [9]. It consists of 12 questions.

Table 1

Distribution of QoL scores and inflammatory markers.

Category	Day-1	1 month	2 months	4 months	6 Months	Comments
Total IOFQLI score (60)	14	26	37	49	59	p = 0.03
Pain	1	2	3	4	5
Stiffness	1	2	3	4	5
Numbness	2	3	4	5	5
Disturb	2	3	4	5	5
Wash or dry hair	1	2	3	4	5
Turn a door	1	2	2	3	5
Writing	1	2	3	4	5
Problem with working	1	2	3	4	5
Bicycle riding	1	2	3	4	5
Support with others	1	2	3	4	5
Other activities	1	2	3	4	5
QoL	1	2	3	4	4
ESR	114	94	56	34	22	p = 0.02
CRP	76	34	<5	<5	<5	p = 0.03

p < 0.05 considered significant. ESR-erythrocyte sedimentation rate (mm/first hour); CRP-C reactive protein (mg/L) Grade 1 = no improvement, grade 2 = poor improvement, grade 3 = moderate improvement, grade 4 = much improvement and grade 5 = full improvement.

All parameters in QoL showed sequential improvement and reached to maximum after 6 months (Table 1). Comparisons of the QoL scores on different period of the treatment shows significant difference between the mean of QoL scores, day one comparing with day 90 and day 90 comparing with day 180 (p = 0.03) (Annexure 1). Compared to first visit, ESR (p = 0.02) and CRP (p = 0.03) declined and at the 4th month were significant.

Discussion

With modern treatment methods, most fractures heal without any problems. Some fractures do not heal even when they get the best surgical or non-surgical treatment. In some cases, certain risk factors make it more likely that a bone will fail to heal. When a fracture fails to heal, it is called as a “nonunion” [10]. The reasons for nonunion include avascular necrosis, the two ends are not apposed, infections like osteomyelitis, improper fixture of the fracture and soft-tissue imposition. The study case was a young patient and past medical history revealed that he was healthy and devoid of any metabolic disorders. The patient ended up in nonunion following failure of internal fixation. The prognosis of nonunion depends on many factors such as the age and general health condition, time period from the original injury, previous surgeries and smoking.

In the current traditional system of medicine in Sri Lanka, the fracture management is combined with Ayurveda and native orthopedic system. Traditional medical system is esteemed to own plenty of effective herbal preparations that are capable of increased fracture healing activity and antimicrobial properties. Hence, once applied on the immobilized fracture site, these medicinal preparations would enhance the healing of fractured bone and lead to proper reunion. Ayurveda has a basic treatment protocol for fracture management of Sodhana, Shamana and Tarpana. Treatment initiates following Sodhana and subsequently Shamana Karma follows with Tarpana treatment [10], [11]. Sodhana Chikitsa (purificatory treatment) is one of the treatment methods of Purva Karma (preparatory therapy). For the Purva Karma (preparatory therapy), Snehana Karma (oleation therapy) was applied on the fractured area. According to this concept, Seethodaka Oil Picu (oil with a gouse) as a Bahya Chikitsa (external treatment) was used for purification of the fractured area [7]. In this study we have used Seethodaka oil for Sodhana Chikitsa (purificatory treatment) which consists of Nimba (Melia azadirachta) also has Vrana Sodana (wound purificatory) and Vrana ropanas (wound healing) effects [12]. It is purifies the blood surrounding the fractured area and regulates blood circulation around the non-healing wound as well as non-healing fracture.

Blood circulation around the fractured bone was regularized after Sodhana Chikitsa. It initiates the formation of hematoma and subsequently resolves into granulation tissue with the typical inflammatory cascade. In the case of chronic nonunion, Sodhana treatment would trigger the granulation tissue formation which subsequently leads to soft callus and finally triggers the hard callus formation. Sodhana treatment was given for around eight weeks. Once Shamana treatment was initiated, a state of balance between osteoclast and osteoblast activities of seen which will strengthened the callus. With Tarpana treatment, the homeostatis proceeded with bone remolding and lead to final bone formation with complete fracture healing [13], [14]. While continuing above therapy based on Susrutha Samhita for proper fracture healing, Kusha (splints), Alepa (paste or plaster) and Bandana (bandaging) needed to be done to stabilize the fracture [7].

Conclusion

This patient's motor function and QoL improved significantly without further corrective surgery including bone grafting. This case study signifies that the application of Ayurvedic and traditional orthopedic treatments are effective in fractures following nonunion. A follow-up large sample study will be important to assess the efficacy of given Ayurveda treatment protocol.

Sources of funding

None.

Conflict of interest

None.

Comparisons	Before treatment (Mean ± SE)	After treatment (Mean ± SE)	T-value	Probability value
Day 1–3 month	1.16 ± 0.11	3.08 ± 0.14	23	0.000Significant
3month–6 months	3.08 ± 0.14	4.91 ± 0.08	11	0.000Significant
Day1–6 months	1.16 ± 0.11	4.91 ± 0.08	28.72	0.000Significant