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Principles in the Management of 

Fractures - A study on Susrutha in 

comparison with the contemporary 

Concepts. 

Prof.G.S.Raju, M.D.(Ay) 

P.G.Dpt.Of Salyatantra, 

Alva’s Ayurveda Medical 

College,Moodbidre, D.K.Dt, 

Karnataka. 

Tel : 0471-2345325(Res) 

Cell: 09447068486 

5/11/2011 9:30:17 AM 1

5/11/2011 9:30:17 AM 2

5/11/2011 9:30:17 AM Prof.G.S.Raju.M.D.(Ay) 3

Definition 

“A fracture may be a complete or an 

incomplete break in the continuity of a bone, or 

a crack”. (J.C.Adams) 

Causes 

A relatively severe trauma is 

necessary to cause a fracture. 

The same clinical condition is referred to as 

“Bhagna” in the Ayurvedic texts. 


Fracture is of different types according to 

the type and shape of the bone involved. 

‣Cartilages rarely break into fragments resulting 

in a typical fracture.They tend to bend causing 

greenstick type of fracture. 

‣Typical fracture occur in long bones. 

‣Fissures appear in flat bones. 

‣Irregular bones may crack and fall down. 


Aetiology of fractures 

‣Fall 

‣Compression 

‣Blow with iron or wooden rods 

‣Strong pulling force 

‣Bite or attack by wild animals etc. are 

considered as predisposing factors of a 

fracture. 


Where the violence is severe – 

‣ More than one bone is involved. 

‣ Fracture is seen at multiple sites of the same 

bone. 

‣ Both the shaft and joint is involved. 

In certain diseases,bones undergo fracture 

even in the absence of trauma,which is known as 

Pathological fracture. 


Classification of fractures 

KANDA BHAGNA 

SANDHI BHAGNA (SANDHI MUKTA) 

Each of this is sub classified into different 

varieties. Criterion behind the terminology is the 

shape,displacement of fragments and the age 

factor. 


Sub classification of KANDA BHAGNA 

Karkatakam Asthychallitam Vakram 

Asvakarnam 

Kandabhagnam Chinnam 

Choornitham 

Majjanugatham Patitham 

Pichitham Athipathitham Sputitham 


Clinical features and differential diagnosis 

Karkatakam 

‣ Visheshatastu 

Sammodam ubhayatho 

asthimadhye bhagnam 

grandhi eva unnatham 

‣Fragments not 

displaced. 

‣Fracture confined 

to the shaft. 

‣Site of fracture is 

elevated. 


Aswakarnam 

‣ Aswakarnavat 

udgatham 

Aswakarnam 

‣Pattern of 

fracture is oblique 

‣Fragments are 

elevated and/or 

displaced. 


Choornitham 

‣ Sprushyamane 

sabdavat churnitham 

Avagachet 

‣ The number of 

fragments are 

multiple. 

‣ Multidirectional 

crepitus. 


Pichitham 

‣Pichitham pruthutham gatham 

analpashopham 

‣Involvement of soft structures at the site 

of fracture. 

‣Separation from the remainder of the 

body 

‣Quick and extensive onset of swelling. 


Asthichallitham 

‣ Parshvayorasthi 

heenodgatham 

Asthichallitham 

‣ Shape of fracture 

longitudinal. 

‣ Size of fragment is 

small. 

‣ Limited to the 

periphery of the bone. 


Kandabhagnam 

‣ Vellathey 

prakampamanam 

kanda bhagnam. 

‣ Type of fracture is 

transverse. 

‣ Displacement of 

fragments present. 

‣ Tremors felt on 

attempted movements. 


Majjanugatham 

‣ Asthi avayavo asthi 

madhyam 

anupravishya 

majjanam unahyathithi 

majjanugatham. 

‣ Fragments impacted. 

‣ Crepitus and abnormal 

mobility absent. 


Atipatitham 

‣Asthi nissheshatah chinnam atipathitham 

‣These are usually caused by mechanical 

injuries resulting in complete loss of 

original shape,which is permanent. 


‣ Abhugnam 

avimukthasthi 

Vakram 

‣ Absence of features of 

a typical fracture. 

‣ Shaft is bent and 

fracture incomplete. 

‣ Visible external 

deformity. 

5/11/2011 9:30:17 AM 

Prof.G.S.Raju.M.D.(Ay) 

18

Chinnabhagnam 

‣ Anyanthara 

parshwvashistam 

chinnam 

‣ Fracture is incomplete. 

‣ One side of the bone 

remain unbroken. 


Patithabhagnam 

‣Patitham anu bahu vidaritham vedanavatcha 

‣Appearance of fissures over the flat bones. 

‣Number of fissures may be multiple and 

small in size. 

‣Severe pain. 


Sputithabhagnam 

‣Sooka purnamivadmatham vipulam 

visputikrutham sputitham 

‣Severe pain. 

‣Multiple fracture/cracks at different sites. 

‣Small bones,teeth etc. are involved. 


The different terminologies given to the 

types of fracture is based upon - 

‣ Change in the shape at the site of fracture. 

‣ Typical nature of displacement. 

‣ Number of fragments. 

‣ Type of the bone involved. 

‣ Size of the bone involved. 

‣ Extent of injury. 

‣ Age. 


Different schools of fracture classification – 

Contemporary Orthopaedics 

A. Fractures caused solely by sudden 

injury. 

1. Direct fracture – which occur at the 

site of trauma. Eg. Fracture at the lower end 

of radius on fall with outstretched hands. 

2. Indirect fracture – which occur 

distal to the site of trauma. Eg. Fracture head 

of radius, fracture to clavicle etc. in fall with 

outstretched hands. 


B. Fatigue fracture/Stress fracture - which 

occur not from a single violent injury but from 

often repeated stress. Eg. Fracture to 

metatarsals,Fibula,Tibia etc. This also is known 

as March fracture. 

C. Pathologic fracture - occur through bones 

which are already weak by diseases.Onset is 

spontaneous. Causes are- 

1.Local diseases of bones 

2.Congenital diseases 

3.Metastatic lesions 


Local diseases are caused by – 

a) Infections d) Benign/Malignant tumors 

b) Syphilis e) Simple bone cyst etc. 

c) Bone atrophy 

Congenital diseases are - 

a) Osteogenesis imperfecta d) Infantile rickets 

b) Senile osteoporosis e) Multiple Myeloma 

c) Cushing’s syndrome 

Metastatic lesions are - 

a) Benign/malignant tumors b) Tuberculosis etc. 


D. Classification based upon the wound 

accompanying the fracture – 

(a) Simple fracture 

OR 

Closed fracture 

(b) Compound fracture 

OR 

Open fracture 


‣Simple or closed fracture is that - where there is no 

communication between the site of fracture and 

exterior of the body. 

‣Compound fracture or open fracture is that - when 

there is a direct communication established between 

the site of fracture and the exterior of the body. 

‣Such a parameter of classification is not seen in the 

Ayurvedic texts,with an exception to - 

Pichitha bhagnam which is classified into 

1.Savrana and 

2.Avrana bhagna. 


E. Another method in the contemporary works is 

indicative of the causative injury/type of bone 

involved/type of displacement of fragments. 

* Greenstick fracture * Compression fracture 

* Infraction * Oblique fracture 

* Avulsion fracture * Spiral fracture 

* Epiphyseal separation * Transverse fracture 

* Comminuted fracture * Pathologic fracture 

* Intra Articular fracture 


Pattern of fracture 

Generally used terms are – 

* Transverse fracture * Oblique fracture 

* Spiral fracture * Comminuted fracture 

* Compression fracture * Greenstick fracture 

* Impact fracture 

Pattern of fracture denote - 

* The causative violence 

* Easiest method of reduction 

5/11/2011 9:30:17 AM Prof.G.S.Raju.M.D.(Ay) 29 

* Stability of fragments

Comparison 

Kanda bhagnam & Transverse fracture 

Karkatakam 

Aswakarnam Oblique fracture 

Choornitham 

Comminuted fracture 

Vakram Greenstick fracture 

Majjanugatham Impact fracture 


Clinical features of a fracture 

‣ Swayathu Bahulyam (Diffuse swelling at the site of 

fracture) 

‣ Spandana Vivarthana Sparshrsahisnutwam (Loss of 

movement of the part and tenderness) 

‣ Avapeedyamane Sabda (Crepitus) 

‣ Srashtangatha (Flaccidity of muscle) 

‣ Vividha Vedana Pradurbhava (Pain of varying nature) 

‣ Sarvasthasu na sarmalabha (No relief in pain at any 

position and overall restlessness) 


Due to the force of violence ---- 

‣ Smooth tissues around the bone are injured 

exudation of fluid Oedema. 

‣ Extra vasation of blood Oedema. 

‣ Oedema is increased in direct fracture. 

‣ Closed fracture is aseptic. 

‣ Pressure exerted by fragments upon nerve ends 

Pain. 

‣ Severe pain/injury to nerves Loss of movement. 

‣ Grating of fragments Crepitus. 

‣ Loss of continuity of bone Loss of integrity. 


Symptoms vary from bone to bone, still general 

features are- 

* Swelling * Continuous pain 

* Loss of function of the affected part. 

Signs of fracture 

* Visible/palpable deformity * Local swelling 

* Visible bruising/Echymosis * Local Tenderness 

* Marked impairment of function 

Unmistakable evidences are…. 

* Abnormal mobility between fragments 

* 

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Crepitus 

9:30:17 AMon attempted 


movements. (J.C.Adams) 

33

Diagnosis of fracture: 

Local Symptoms 

General symptoms 

Local symptoms are : 

* Pain * Deformity 

* Swelling * Crepitus 

* Loss of function * Difference in length 

General symptoms are : 

* Fever * Shock * Delerium 

* Fatembolism * Hemorrhage * Necrosis 


Presence of a fracture can almost be inferred from : 

* History presented by the patient 

* The clinical symptoms 

But radiographs are necessary to establish the excact 

nature of the fracture. 

Some fractures may be overlooked- Eg: 

* Pathological fracture * Greenstick fracture 

* Impact fracture * Fatigue fracture 

* Fracture of small bones. 


Radiographic Examination. 

• Clinical evidence of a fracture should always be 

confirmed by radiographic examination,whereby 

no fracture is overlooked. 

• Standard method is to have two projections in 

planes- Usually Antero- Posterior and Lateral. 

• The film should include sufficient length of the 

bone above and below the site of fracture. 


Prognosis of fracture is poor in ---- 

* Choornitha Bhagnam 

* Atipatitha Bhagnam 

* Majjanugatha Bhagnam 

* Fracture in - (a) Extremely emaciated 

patients (b) Elderly individuals (c) Infants and 

children (d) Fracture in persons already weak by 

injuries (e) Patients with respiratory disorders. 


Fracture to certain bones and joints are also with poor 

results. They are – 

* Fracture to flat bones of the pelvis and cranial 

vault. 

* Crush fracture of pelvis. 

* Fracture of suture joints. 

* Fracture to sternum,spine,temporal bone etc. 

* Bones and joints with congenital anomaly. 

* Fracture in which displacement of fragments 

relapse. 

Time span required for healing of fractures is also 

described by Susrutha in detail. 


Management of Fractures. 

When the diagnosis of fracture has been 

made,additional examination is to be done to 

determine the following - 

‣ Is there a wound communicating with the 

fracture 

‣ Is there any impairment of circulation 

‣ Is there any evidence of nerve injury 

‣ Is there any evidence of visceral injury 


The X-ray film must be well examined to ascertain – 

‣ Is the fracture an ordinary traumatic 

fracture/Fatigue fracture/Pathologic fracture 

‣ Are the fragments displaced 

‣ Are the fragments in satisfactory alignment 

‣ Is the fracture a recent one 

‣ Any evidence of callus tissue 

‣Is there any injury to the neighboring bone or joint 

‣ Is there any features suggesting degeneration 


Before any definitive treatment, sufficient care is to 

be directed to ---- 

‣First aid treatment. 

‣Measures to control bleeding (if present). 

‣Measures to overcome shock. 

‣Special care in transportation for patients with spinal 

injury. 

‣Traction to the fractured limb while moving the 

patient (Lower limb). 

‣Around the chest bandage or a sling for upper limb 

injuries. 

‣Maintenance of a clear air way and pulmonary 

ventilation. 


Definitive treatment. 

Objectives:- 

* Approximation of bone ends. 

* Realignment of fragments as far as possible. 

* Immobilization till healing. 

In other words, the principles can be summarized as 

REDUCTION 

IMMOBILIZATION 

 

PRESERVATION OF FUNCTION 


Reduction. 

* Application of logical sequence of forces to 

reverse the deformity caused by the fracture is called 

Reduction. 

* In many fractures, reduction is 

unnecessary. Eg:Fracture to clavicle,spine,small bones 

etc. 

* If reduction is decided, it is carried out as – 

‣Closed manipulative reduction. 

‣By mechanical traction. 

‣Operative 5/11/2011 9:30:17 AM reduction Prof.G.S.Raju.M.D.(Ay) with or without internal fixation. 43

Closed manipulative reduction is the initial 

standard method in most of the fractures. 

Procedure:- 

‣ Grasp the fragments through soft tissue. 

‣ Disimpact the fragments if necessary. 

‣ Adjust the fragments as nearly as possible to the 

original shape. 

‣ When the epiphysis is involved, the reduction 

should be excellent. 

‣ Intra articular fracture also require excellent 

reduction. 


Immobilization. 

It also is not necessary in all fractures. 

Eg:Fracture clavicle. 

Immobilization helps in – 

‣ Prevention of displacement of fragments. 

‣ Prevention of angulations. 

‣ Prevention of excess movements. 

‣ Relief from pain and swelling. 

‣ Retaining sufficient contact between fragments 

which help in healing. 


Immobilization is carried out by:- 

 

 

 

 

P.O.P. Cast 

External splints. 

Continuous traction. 

Internal fixation. 

* Immobilization should include the joints distal and 

proximal to the site of fracture. 

* Care to prevent possible ischaemia distal to the site 

of fracture. 

* Internal fixation is decided to hold the fragments in 

5/11/2011 9:30:17 AM Prof.G.S.Raju.M.D.(Ay) 46 

acceptable position and to secure earlier mobility.

Open or compound fracture require ---- 

‣ Urgent surgical attention. 

‣ Cautiously deal with the risk of infection. 

‣ Wound should be well cleaned. 

‣ Foreign bodies if present be removed. 

‣ Actual treatment of fracture to start only after 

the wound has been properly dealt with. 


Rehabilitation – is one of the very important 

principle in fracture treatment. 

Objective - is to use the limb freely and as early 

as possible. 

Specific exercises and other arrangements should 

be advised. These methods are collectively called 

Physiotherapy, which has developed into a full 

fledged complementary branch. 

Susrutha very clearly describes the same principles 

along with fracture management. 


Management of fracture and dislocations – 

an Ayurvedic perspective 

Principles: 

‣ Asthy Sthapana (Fixation by reduction) 

‣ Immobilization of the involved part. 

‣ Methods of mobility exercises. 

‣ Application of suitable medicines both internal 

and external. 

‣ Special dietary schedule with rich nutritive 

content. 

‣ Manipulative reduction is advised in fractures 

with displaced fragments. 


Methods of manipulation. 

‣ Lifting of fragments which have been depressed. 

‣ Fragments which protrude have also to be 

depressed. 

‣ Avulsed fragments have to be pulled back into 

position. 

‣ Fragments which have gone down have to be 

lifted upwards. 

Summarizing the methods, he names the technique as 

* Anchana * Unnamana 

* Peedana * Samkshepa 

5/11/2011 9:30:17 AM 

* Bandhana 

Prof.G.S.Raju.M.D.(Ay) 50

Types of bandages. 

* Kosa * Swasthika * Pratholi 

* Cheenam * Damam * Anuvellitham 

* Khatva * Vibandha * Sthagika 

* Vithanam * Utsangi * Gophanam 

* Yamakam * Mandalam * Panchangi 

Proper application of splints and bandage help to 

prevent - 

* Mal union * Non union * Necrosis 

Depending upon the extent of pressure, they are 

brought under three main heads – 

* Gada * Sama * Sidhila 


Removal and reapplication of bandages at regular 

intervals is a unique feature of Ayurvedic fracture 

management. 

Rebandaging is advised once in – 

* 3 days * 7 days * 5 days 

depending upon the climatic variations. 

Stages of healing…. 

‣ Stage of Haematoma 

‣ Stage of Sub periosteal and Endosteal cellular 

proliferation. 

‣ Stage of Callus 

‣ Stage of consolidation 

‣ Stage of remodeling 


Factors influencing healing. 

* Proper nutrition * Proteins and amino acids 

* Calcium * Vitamins A,C & D 

* Hormones (Parathormone, Calcitonin,sex hormones) 

Local factors. 

* Inadequate apposition *Inadequate immobilization 

* Inadequate circulation etc. delay healing. 

Complications related to the fracture itself – 

*Infection * Delayed union * Non union 

* Avascular necrosis * Mal union * Shortening. 


Complications related to associated injuries – 

‣ Injury to major blood vessels. 

‣ Injury to nerves. 

‣ Injury to viscera. 

‣ Injury to tendons. 

‣ Injury and post traumatic affections of joints. 

‣ Fatembolism. 

Failure in union is uncommon in children except 

fracture of Capitulam of Humerus. Supra condylar 

fracture of Humerus has to be very carefully dealt 

with. Fractures involving epiphysis should also be 

dealt with cautiously. 


Symptoms of proper union. 

‣ Site of fracture is free from swelling. 

‣ Site of fracture is not hard on palpation. 

‣ Absence of deformities. 

‣ Absence of protrusion and displacements. 

‣ Resumption of all normal functions. 

‣ Subsidence of pain. 


Some rare cases 










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