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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 127-130

Role of Khanduchakka (Ehretia laevis) Lepan (local application) in the management of delayed union of metatarsal fracture: A case report


Department of Shalya Tantra, Mahatma Gandhi Ayurved College, Hospital and Research Centre, Salod (Hi)Wardha, Maharashtra, India

Date of Web Publication21-Nov-2019

Correspondence Address:
Dr. Sr. Suraj V Tichkule
Shalyatantra Department, Mahatma Gandhi Ayurved College, Hospital and Research Centre, Salod (Hi) Wardha, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_26_19

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  Abstract 

Background: The application of Khanduchakka (Ehertia Laevis) Kalka (paste) in the case of Delayed-union of metatarsal fracture is an innovative idea. It is a case report having the fracture of 3rd and 4th metatarsal of right foot. Ehertia Laevis is folklore plant locally known as Khanduchakka used in fracture and wound healing in various forms by the tribal people. In the present case it is used as Lepan (local application). Observation after treatment shows that the Ehertia Laevis is an effective alternative treatment for fracture and delayed union of bones without any complications. Aim: To evaluate healing effect of Khanduchakka Lepan in the management of Delayed union of Metatarsal fracture. Material and Method: In this present case report, the patient with Delayed union of Metatarsal fracture was treated with Khanduchakka Kalka used as local application after all the mandatory investigations and its efficacy was evaluated on the basis of clinical parameters like pain, swelling and fracture healing. Statistical analysis used: 1. Universal Pain Assessment Tool i.e. Visual Analog Scale (VAS) scoring for pain. 2. Swelling was assessed by measuring affected foot circumference in centimeters. 3. American Orthopedic Foot and Ankle Scale (AOFAS) result was calculated. Results: Patient showed significance results in clinical parameters evaluated. He got partial relief within 2 weeks. Conclusion: X-Ray revealed that there was callus formation and the mal-union was slightly aligned just by simply applying Khanduchakka Kalka over a fracture. Visual analog scale used for pain showed before treatment score - 8/10 and after treatment score - 2/10. Circumference of swelling reduced from 33cm to 29cm. AOFAS score was improved from 38/100 to 79/100 points. Therefore it can be concluded that this intervention not only acts as fracture healing but also relieved symptoms of pain and swelling.

Keywords: Delayed union of metatarsal fracture, Ehertia laevis (Khanduchakka), fracture, Kalka, Lepan


How to cite this article:
Tichkule SV, Khandare KB, Shrivastav PP. Role of Khanduchakka (Ehretia laevis) Lepan (local application) in the management of delayed union of metatarsal fracture: A case report. J Indian Sys Medicine 2019;7:127-30

How to cite this URL:
Tichkule SV, Khandare KB, Shrivastav PP. Role of Khanduchakka (Ehretia laevis) Lepan (local application) in the management of delayed union of metatarsal fracture: A case report. J Indian Sys Medicine [serial online] 2019 [cited 2020 Jan 26];7:127-30. Available from: http://www.joinsysmed.com/text.asp?2019/7/2/127/271410




  Introduction Top


Sushruta is the father of surgery, if the history of science is traced back; he was a specialist in dental, cosmetic, and plastic surgery (Sandhan Karma) including general surgery around 600 BC. Besides trauma involving general surgery, Sushruta gives a detailed account and an explanation of the treatment of 12 multiplicities of Kandabhagna (fracture) and six categories of Sandhimoksha (dislocation). This knowledge continued to orthopedic surgeons even in modern era.[1] Sushruta’s treatment for fracture mentions the principles of traction, manipulation, stabilization, apposition, and postoperative physiotherapy with normal functioning of fracture.[2],[3] Sushruta has also revealed the splints of different plants such as Udumber (Ficus glomerata), Madhuk (Glycyrrhiza glabra), and Ashvatha (Ficus religiosa), which are tough in consistency for immobilization.[4]

Modern concept of fractures.[5] It is based on extent of fracture line, simple compound, and fracture pattern. When the process of fracture healing takes more than the usual time to unite, it is said to have gone in delayed union. The usual time for healing takes around six months, so the diagnosis is labeled after this period. Diagnosis of nonunion can be carried out based on the clinical findings such as persistent pain, pain, on stressing the fracture and swelling at the site of fracture. Although radiological features suggest that the fracture line is visible, there may be inadequate callus bridging the fracture site.

Crush injuries to the foot involve metatarsal, and ligament tear that typically occurs within industrial workplaces represents a distinct type of metatarsal trauma.[6]

Fracture healing includes primary and secondary forms of bone healing. The primary form of bone healing can be achieved by implantation, in which bony fragments are fixed together tightly under compression. Healing occurs directly by osteoclasts and osteoblast activities without the formation of callus between two bony fragments that are connected together. The secondary bone healing take places when there is a motion of small amount at the fracture site. Soft callus formation took place through both intramembranous and endochondral ossifications at the time of motion between two fracture bones. Bone healing begins with the anabolic phase and joins with the catabolic phase as soon as callus volume is reduced. Resulting in the bone remodeling phase begins by organized osteoblast and osteoclast activities over a span of several months. Last stage includes reabsorption of callus tissues leading to lamellar bone formation. Surgical treatment includes bone grafting with or without internal fixation, percutaneous pinning, and excision of fragments or cast immobilization. After healing process when the cast or splint is removed, a physical therapy is required for the muscular stiffness.[7]

Ehretia laevis is a small tree generally found in Asia and Australian tropics.[8] Leaves of Khanduchakka are applied to ulcers and in headache.[9] In periphery of Wardha, it is used for fracture healing, wound healing, and other purposes.[10] Research-based evidence shows that Ehretia laevis is used for the management of wound or ulcer, but there is no research evidence found regarding fracture healing.

This leads to research Khanduchakka as a new modality of fracture healing, whereas its other properties help in reducing the other symptoms such as pain and swelling.


  Case History Top


A 45-year-old male patient came to OPD with metatarsal fracture with complaints of swelling, pain, and difficulty in walking. Patient gave a history of bike driven over his right foot 11 years ago. The patient was admitted for the same. No surgical intervention was carried out and that time it was managed with cast application only, which was removed early because of itching and other reasons as told by the patient. Till coming to us, patient was performing his farming work, which was strenuous and as foot is a weight bearing joint it resulted in swelling, pain, and difficulty in walking. After resting symptoms used to get reduced, but day by day because of strenuous work symptoms were increasing and patient denied for surgical intervention.

On examination of right foot swelling [Figure 1] with pitting edema was present, while walking patient used to take help of support. X-ray findings showed fracture in the shaft of the third and fourth metatarsal with inadequate callus formation with sharp edges at fracture site of bone, which typically indicates delayed union of bone [Figure 3]. The main reason for delayed union must be lack of immobilization because of continued strenuous work before healing of the fracture. Expert opinion was taken from orthopedic surgeon and based on that it was decided that no surgical intervention is needed. Routine examinations were within normal range. Therefore, the patient was admitted for the treatment as per schedule. Dressing was started on daily basis for two weeks.
Figure 1: Image of right foot before treatment

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Figure 3: X-ray of right foot before treatment

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Ehretia laevis Kalka Lepan

Kalka was prepared from Ehretia laevis leaves. Fresh leaves were collected from surrounding area, which were used traditionally in Wardha district. In total, 10–15 leaves were grinded with water to make it a preparation of Kalka as mentioned in ayurvedic classic.[11] The purpose of immobilization was achieved by Plaster of Paris (POP) backslab given over the dressing of Kalka. The dressing was carried out on daily basis.


  Procedure of Dressing and Plaster Application Top


  1. Kalka was prepared and applied all over the foot. Cotton pad and cotton roll were applied firmly. The thickness of Kalka was of 0.5–1cm. This Kalka Lepana was kept for 24h each day with the dressing.


  2. Thin rubber pad was covered over the dressing to maintain the consistency of POP backslab for hardness.


  3. Backslab made up of POP was applied over the dressing on the side of sole and posterior side of lower leg.


  4. Bandage roll was again applied over the whole part of foot and lower leg.



  Materials and Methods Top


  1. Type of study: case study.


  2. Duration of study: two weeks.


  3. Sample size: one patient.


  4. Data procuring sources: Mahatma Gandhi Ayurved College, Hospital and Research Centre, Salod (Hirapur), Maharashtra, India.


  5. Methods:


  • Randomly selected fracture case, which does not need surgical intervention.


  • Preparation of Khanduchakka lepan and POP backslab followed by application on daily basis for two weeks. New Kalka lepana and dressing were used every day and the same backslab was used in the entire study.


  • Observations were performed based on the VAS and AOFAS scales.


  • Data were collected and analyzed.



  Observations and Results Top


It was observed that within 10 days of Lepan, swelling and pain was reduced gradually [Figure 2] and patient became able to walk without support. Clinically relevant end point of functional test for lower extremity can be pain free full weight bearing,[12] which was partially achieved after treatment in the present case. The callus formation process was not acceptable before the treatment became acceptable after the intervention [Figure 4]. Visual Analog Scale (VAS) scoring for pain was performed based on the Universal Pain Assessment Tool and swelling was assessed by measuring the circumference of the affected foot in centimeters [Table 1]. The American Orthopedic Foot and Ankle Scale (AOFAS) result was also drawn.[13]
Figure 2: Image of right foot after treatment

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,
Figure 4: X-ray of right foot after treatment

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Table 1: Results of delayed union fracture assessment

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  Discussion Top


Logical description of fracture and dislocation along with their treatment principle is described in ayurved, which are practiced even in today’s modern era. In the present case, report of delayed union of metatarsal fracture was treated by using Khanduchakka Kalka Lepana on daily basis for two weeks and patient was advised for immobilization of foot. The assessment of the delayed union fracture was performed based on VAS score, AOFAS score, and reduction of swelling (circumference) in centimeters. It was observed that the intervention worked significantly. Pain and swelling was significantly reduced, whereas AOFAS result showed a good reduction in percentage [Table 1]. Khanduchakka has been used traditionally for healing fracture and wounds since long period. As it was not having any scientific base, this study was conducted to evaluate its efficacy in healing fracture. It is difficult to assess the probable mode of action of Khanduchakka in fracture healing but it gave us a ray of research to find out the same. The demerit that we face in Khanduchakka Lepan was every time fresh leaves that have to be collected for the preparation of Kalka and it was quite difficult to apply the posterior slab and bandaging daily to the patient which was a chaotic procedure. Keeping all this in mind, further study can be conducted.


  Conclusion Top


In this single case study, on the basis of results it can be concluded that Khanduchakka Lepan is a good alternative modality for treating a fracture. Ehretia laevis has contents such as ursolic acid, rutin, betulin, and lupeol, which acted as an anti-inflammatory that has been seen in earlier studies related to it also. With this B-sitosterol reduced pain and swelling. Key role was of arginine (amino acid), which is used worldwide in dental products which helped in reducing healing time of fracture site, whereas napthoquinone controlled the neuronal damage and was used in fracture healing as well.[14] At the same time to evaluate its unbiased efficacy, it is required to conduct the intervention on a large sample size.

Therefore, further research work to evaluate the efficacy of Khanduchakka in the management of fracture is warranted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yadavji T. Chikitsa Sthan.In: Sushrut Samhita, 3/18–19; Reprint ed. Varanasi, India: Chaukhambha Orientalia; 2007. p. 416.  Back to cited text no. 1
    
2.
Yadavji T. NidanSthan.In: Sushruta Samhita, 15/4; Reprint ed. Varanasi, India: Chaukhambha Orientalia; 2007. p. 328.  Back to cited text no. 2
    
3.
Yadavji T. Chikitsa Sthan.In: Sushrut Samhita, 3/35; Reprint ed. Varanasi, India: Chaukhambha Orientalia; 2007. p. 417.  Back to cited text no. 3
    
4.
Yadavji T. Chikitsa Sthan.In: Sushrut Samhita, 3/6; Reprint ed. Varanasi, India: Chaukhambha Orientalia; 2007. p. 415.  Back to cited text no. 4
    
5.
Maheshwari J. Essentials of Orthopedics. 3rd ed. New Delhi, India: Mehta Publishers; 2010. p. 38.  Back to cited text no. 5
    
6.
Petrisor BA, Ekrol I. The epidemiology of metatarsal fractures. Foot Ankle Int 2006;27:172-4.  Back to cited text no. 6
    
7.
Mohammad S, Ghiasi J, Chen A. Bone fracture healing in mechano-biological modeling: A review of principles and methods. Bone Rep 2017;6:87.  Back to cited text no. 7
    
8.
Available from: http://www.henriettesherbal.com/eclectic/sturtevant/ehretia.html.  Back to cited text no. 8
    
9.
Joshi SG. Medicinal Plants. New Delhi, India: Oxford and IBH Publishing Co. Pvt. Ltd.; 2000. p. 102.  Back to cited text no. 9
    
10.
Dhenge S, Khandare K. Efficacy of local application of Khanduchakka (ehretialaevisroxb) ghrita in dushtavrana––a case report. IAMJ 2016;4:3727.  Back to cited text no. 10
    
11.
The Ayurvedic Formulary of India. Govt. of India. New Delhi, India: Ministry of Health and Family Welfare; 1978. p. 1-120. Anonymous. [Google Scholar]  Back to cited text no. 11
    
12.
Shisha T. Parameters for defining efficacy in fracture healing. Clin Cases Miner Bone Metab 2010;7:15-6.  Back to cited text no. 12
    
13.
http://orthotoolkit.com/aofas-ankle-hindfoot/.  Back to cited text no. 13
    
14.
Thakre R, Bhutada S, Bharat C, Pramod K, Ravindra KH . Ethano botanical properties of unexplored plant Khandu chakka (Ehretia laevis ROXB.). IJAPR 2016;4:69-72. Retrieved from https://ijapr.in/index.php/ijapr/article/view/373.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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