Bone healing, or fracture healing.

 Bone healing is a proliferative physiological process in which the body facilitates the repair of a bone fracture.

1-Generally bone fracture treatment consists of a doctor reducing (pushing) displaced bones back into place via relocation with or without anaesthetic, stabilizing their position to aid union, and then waiting for the bone's natural healing process to occur.

2-Adequate nutrient intake has been found to significantly affect the integrity of the fracture repair. Age, Bone type, drug therapy and pre existing bone pathology are factors which affect healing. The role of bone healing is to produce new bone without a scar as seen in other tissues which would be a structural weakness or deformity.

3-The process of the entire regeneration of the bone can depend on the angle of dislocation or fracture. While the bone formation usually spans the entire duration of the healing process, in some instances, bone marrow within the fracture has healed two or fewer weeks before the final remodeling phase.

4-While immobilization and surgery may facilitate healing, a fracture ultimately heals through physiological processes. The healing process is mainly determined by the periosteum (the connective tissue membrane covering the bone). The periosteum is one source of precursor cells which develop into chondroblasts and osteoblasts that are essential to the healing of bone. The bone marrow (when present), endosteum, small blood vessels, and fibroblasts are other sources of precursor cells.

There are three major phases of fracture healing

1. Reactive phase

       Fracture and inflammatory phase

  Granulation tissue formation

2. Reparative phase

       Cartilage callus formation

      Lamellar bone deposition

3. Remodeling phase

    . Remodeling to original bone contour

Reactive

After fracture, the first change seen by light and electron microscopy is the presence of blood cells within the tissues adjacent to the injury site. Soon after fracture, the blood vessels constrict, stopping any further bleeding. Within a few hours after fracture, the extra vascular blood cells form a blood clot, known as a hematoma. These cells release cytokines and increase blood capillary permeability. All of the cells within the blood clot degenerate and die. Some of the cells outside of the blood clot, but adjacent to the injury site, also degenerate and die. Within this same area, the fibroblasts survive and replicate. They form a loose aggregate of cells, interspersed with small blood vessels, known as granulation tissue. This tissue reduces strain across the fracture site. Osteoclasts move in to reabsorb dead bone ends and other necrotic tissue are removed.

Reparative

Days after fracture, the cells of the periosteum replicate and transform. The periosteal cells proximal (closest) to the fracture gap develop into chondroblasts which form hyaline cartilage. The periosteal cells distal to (further from) the fracture gap develop into osteoblasts which form woven bone. The fibroblasts within the granulation tissue develop into chondroblasts which also form hyaline cartilage. These two new tissues grow in size until they unite with their counterparts from other parts of the fracture. These processes culminate in a new mass of heterogeneous tissue which is known as the fracture callus. Eventually, the fracture gap is bridged by the hyaline cartilage and woven bone, restoring some of its original strength.

The next phase is the replacement of the hyaline cartilage and woven bone with lamellar bone. The replacement process is known as endochondral ossification with respect to the hyaline cartilage and bony substitution with respect to the woven bone. Substitution of the woven bone with lamellar bone precedes the substitution of the hyaline cartilage with lamellar bone. The lamellar bone begins forming soon after the collagen matrix of either tissue becomes mineralized. At this point, the mineralized matrix is penetrated by channels, each containing a microvessel and numerous osteoblasts. The osteoblasts form new lamellar bone upon the recently exposed surface of the mineralized matrix. This new lamellar bone is in the form of trabecular bone.^[12] Eventually, all of the woven bone and cartilage of the original fracture callus is replaced by trabecular bone, restoring most of the bone's original strength.

Remodelling

The remodeling process substitutes the trabecular bone with compact bone. The trabecular bone is first resorbed by osteoclasts, creating a shallow resorption pit known as a "Howship's lacuna". Then osteoblasts deposit compact bone within the resorption pit. Eventually, the fracture callus is remodelled into a new shape which closely duplicates the bone's original shape and strength. The remodeling phase takes 3 to 5 years depending on factors such as age or general condition. This process can be enhanced by certain synthetic injectable biomaterials, such as cerament, which are osteoconductive and actively promote bone healing.

Obstructions to Bone Healing

1.   Poor blood supply which leads to the death of the osteocytes. Bone cell death is also dependent on degree of fracture and disruption to the Haversian system.

2.   Condition of the soft tissues. Soft tissue in between bone ends restrict healing.

3.   Nutrition and drug therapy. Poor general health reduces healing rate. Drugs that impair the inflammatory response impede healing also.

4.   Infection. Diverts the inflammatory response away from healing towards fighting of the infection.

5.   Age. Young bone unites more rapidly than adult bone.

6.   Pre existing Bone malignancy.

7. Fracture healing is determined by mechanical factors and obstructions to healing include the bone not aligned and too much or little movement. Excess mobility can disrupt the bridging callus interfering with union. Slight biomechanical motion is also seen to improve callus formation

The Stages of Wound Healing

1-    Haemostasis,

2-    Inflammation,

3-    Proliferation and

4-    Maturation.

Although the stages of wound healing are linear, wounds can progress backward or forward depending on internal and external patient conditions. The four stages of wound healing are:

Hemostasis Phase

Haemostasis is the process of the wound being closed by clotting.

Haemostasis starts when blood leaks out of the body. The first step of haemostasis is when blood vessels constrict to restrict the blood flow. Next, platelets stick together in order to seal the break in the wall of the blood vessel. Finally, coagulation occurs and reinforces the platelet plug with threads of fibrin which are like a molecular binding agent. The haemostasis stage of wound healing happens very quickly. The platelets adhere to the sub-endothelium surface within seconds of the rupture of a blood vessel's epithelial wall. After that, the first fibrin strands begin to adhere in about sixty seconds. As the fibrin mesh begins, the blood is transformed from liquid to gel through pro-coagulants and the release of prothrombin. The formation of a thrombus or clot keeps the platelets and blood cells trapped in the wound area. The thrombus is generally important in the stages of wound healing but becomes a problem if it detaches from the vessel wall and goes through the circulatory system, possibly causing a stroke, pulmonary embolism or heart attack.

Inflammatory Phase

Inflammation is the second stage of wound healing and begins right after the injury when the injured blood vessels leak transudate (made of water, salt, and protein) causing localized swelling. Inflammation both controls bleeding and prevents infection. The fluid engorgement allows healing and repair cells to move to the site of the wound. During the inflammatory phase, damaged cells, pathogens, and bacteria are removed from the wound area. These white blood cells, growth factors, nutrients and enzymes create the swelling, heat, pain and redness commonly seen during this stage of wound healing. Inflammation is a natural part of the wound healing process and only problematic if prolonged or excessive.

Proliferative Phase

The proliferative phase of wound healing is when the wound is rebuilt with new tissue made up of collagen and extracellular matrix. In the proliferative phase, the wound contracts as new tissues are built. In addition, a new network of blood vessels must be constructed so that the granulation tissue can be healthy and receive sufficient oxygen and nutrients. Myofibroblasts cause the wound to contract by gripping the wound edges and pulling them together using a mechanism similar to that of smooth muscle cells. In healthy stages of wound healing, granulation tissue is pink or red and uneven in texture. Moreover, healthy granulation tissue does not bleed easily. Dark granulation tissue can be a sign of infection, ischemia, or poor perfusion. In the final phase of the proliferative stage of wound healing, epithelial cells resurface the injury. It is important to remember that epithelialisation happens faster when wounds are kept moist and hydrated. Generally, when occlusive or semi occlusive dressings are applied within 48 hours after injury, they will maintain correct tissue humidity to optimize epithelialisation

Maturation Phase

Also called the remodelling stage of wound healing, the maturation phase is when collagen is remodelled from type III to type I and the wound fully closes. The cells that had been used to repair the wound but which are no longer needed are removed by apoptosis, or programmed cell death. When collagen is laid down during the proliferative phase, it is disorganized and the wound is thick. During the maturation phase, collagen is aligned along tension lines and water is reabsorbed so the collagen fibres can lie closer together and cross-link. Cross-linking of collagen reduces scar thickness and also makes the skin area of the wound stronger. Generally, remodeling begins about 21 days after an injury and can continue for a year or more. Even with cross-linking, healed wound areas continue to be weaker than uninjured skin, generally only having 80% of the tensile strength of unwounded skin.

The stages of wound healing are a complex and fragile process. Failure to progress in the stages of wound healing can lead to chronic wounds. Factors that lead up to chronic wounds are venous disease, infection, diabetes and metabolic deficiencies of the elderly. Careful wound care can speed up the stages of wound healing by keeping wounds moist, clean and protected from reinjury 

HOW TO IMPROVE APPETITE BY AYURVEDA

 Low appetite can be a frustrating problem for people who are underweight or losing weight when they don’t want to. It can be difficult to keep weight on if you aren’t hungry, food doesn’t taste good, or it’s difficult to cook a meal. No matter what the reason, getting adequate nutrition every day can make a big difference in how your body works and how you feel. Consuming enough calories, protein, fat, vitamins and minerals helps to keep muscles strong and healthy and your brain working at an optimal level.
Ways to boost your appetite and make sure you are getting the nutrients you need.

1. Choose nutrient-rich foods

The less you are able to eat, the more nutrient-dense your meals should be. This means focusing on protein, healthy fat, whole grains, fruits and vegetables. Limit empty calories like chips, baked goods, sugar-sweetened beverages and candy, as they don’t provide you with any nutrients.
Eat the biggest meal of the day when you feel hungriest
Starving when you first wake up? This may mean breakfast is a larger meal, while dinner is smaller. Feel hungriest after your lunchtime walk? Make lunch a bigger meal.
Eat smaller meals more often
When your appetite is low, large amounts of food can be a turn off. Instead of three large meals, break these into five or six mini-meals throughout the day.
Limit beverages at meals.
Avoid filling up on fluids before you are done eating. Focus on food first, then have water, coffee, tea, etc after you finish. You want to be sure to get all the nutrients from your foods first, before filling up on liquids that are less nutrient-dense.
Schedule mealtimes
If you never feel hungry, relying on your appetite is not the best cue to eat a meal. Instead, plan your meal times so you remember to eat. If you have a busy day, it can be helpful to set a reminder in your calendar so a meal doesn’t pass you by.
Keep high calorie/protein snacks handy
Have snacks on hand so that if you do feel hungry, you have something available to eat. Try high calorie, high protein snacks such as dried fruit and nuts, peanut butter on crackers, cottage cheese, Greek yogurt, or cheese with crackers.
Experiment with foods
If your taste buds have changed, your typical favorite foods may not taste so good anymore. Experiment with different foods, textures and flavors – you may discover a new favourite meal.
Exercise to increase your appetite
Physical activity can help to make you feel hungrier. Even a walk around the block, combined with fresh air, can stimulate your appetite.
Eat with others
Oftentimes appetite can increase when you are eating a meal with others. If you often eat meals alone, look for more opportunities to eat with others. Invite family or friends over for a meal, or join a social group where people get together for meals.
Drink your calories
If it seems easier to drink than eat, choose high calorie, high protein beverages to help you meet your nutrition needs. Sip on milk, milkshakes, smoothies, soup, or high calorie and protein nutrition supplements.
Home remedies to improve your appetite .
Ginger
Ginger contains a volatile oil that has the property of improving digestion; it also helps to remove the intestinal gas that is produced during the process of digestion. Besides, ginger has a strong flavouring action and a refreshing taste. The best way to make use of these benefits of ginger is to include it in your daily cooking. For better and faster results, you could make some ginger tea, by mixing half a teaspoon of ginger powder into a cup of boiling water and straining it after ten minutes.
Combining ginger with another strong digestive – coriander – also gives good results for a poor appetite. Make a coarse powder of coriander seeds and dried ginger; then mix them in a proportion of 5:1, add into about 100 ml of water and boil till the volume reduces to half and drink the resulting liquid when it is still warm.
Vegetables with appetizer action
Some vegetables are known to contain certain ingredients that have the ability to facilitate digestion and thus, they help to improve the appetite. For example,
1-Raw grated radish mixed with a little curd is a strong appetizer.
2-Raw white onion and
3-Raw cucumber also have strong appetizing properties.
Regular consumption of bitter-tasting foods such as amaranth, fenugreek and bitter gourd also helps to improve the secretion of digestive juices and this helps increase appetite.
Tomato also has the ability to deal with indigestion and can help improve appetite.

Carminative spices
Gas is produced during the process of digestion in the intestine and the presence of this gas is responsible for a heavy feeling.  Besides, it also interferes with the intestines ability to digest the food that enters it and as a result, a person who has abdominal gas will often suffer from a poor appetite. In such cases, it is good to increase the consumption of certain spices that have the property of causing the expulsion of gases – these substances are called as carminatives and they have a powerful digestive action.
Some of the carminative herbs include fennel (saunf),
 1-coriander (dhania),
 2-Mint (pudina),
3-Black pepper (kali mirch) and
4-Cinnamon (dalchini). Include these spices in your regular cooking and you are bound to notice a gradual change in your appetite. You can also sprinkle a little powder of any of these carminatives on vegetables such as tomato or cucumber and consume as a salad for good appetizing action.
Fruits to improve appetite
Certain fruits are known to stimulate hunger and these include
Grapes,
Apples
Black berries.
PAPPYA
DADIM (ANAAR)
Initially after a spinal cord injury, you may experience a decrease in appetite and dietary intake. This can be because of medical problems, changes in mood, poor appetite, difficulty chewing and swallowing, and taste changes.  Inadequate nutrient intake and a decrease in mobility can lead to weight and muscle loss. Weight and muscle loss can result in weakness, feeling tired, and an inability to participate in daily activities.
It is important to consume adequate calories and protein to help maintain energy and muscle mass. The right amount of calories and protein help your body fight infection, maintain muscle mass, and help prevent skin breakdown. If you are underweight, the goal for healthy weight gain is a gain of ½ to 2 pounds per week. This can usually be accomplished by eating at least 250-500 more calories per day than you normally do.
AYURVEDIC FORMULATIONS
AGNITUNDI VATI
CHITRAKADI VATI
LAWANBHASKAR CHURNA
PHALTRIKADI KWATH
DRAKCHASAVA
AMRITARISTA
PHANCHKOL PHANTA
LAWAN ADRAKA
AROGYAVARDHANI VATI

Classification of Laxatives

                    

§  Bulk forming –                                                  Dietary fiber

 Ispaghula

 Methyl cellulose

 Psyllium (plantago)  

                                                    Stool softener-

                                                                  Docusates

                                                                  Liquid paraffin

                                                                                                        Osmotic purgatives

                                                                                                         Magnesium sulfate

                                                                                                         Magnesium hydroxide

                                                                                                         Sodium sulfate

                                                                                                         Sodium phosphate

                                                                                                         Sodium potassium tartrate

                                                                                                         Lactulose

                                             Stimulant purgatives 

                                               Bisacodyl

                                               Sodium picosulfate

                                              Senna

                                              Castor oil

                                              Prucalopride

                                              Phenolpthalein

Ankle disorders

1.      The ankle is the most frequently injured joint in the body.

2.      Treatments include both surgical and nonsurgical .

3.      Most ankle disorders can be prevented by warming up before physical activity.

4.      Your ankle helps to balance and stabilize your body. It’s made up of bones that are supported with muscles and ligaments.

Ankle disorders can result from damage to bone, muscle, or soft tissue. Common ankle disorders include:

·         sprains (injury to ligaments)

·         fractures

·         tendonitis (inflammation of the tendons)

·         arthritis (chronic inflammation of joints)

·          

 

 Causes of ankle disorders

The causes of ankle disorders vary, and can include running, jumping, and overuse. Other common causes of ankle sprains and fractures include:

·         twisting or rotating the ankle beyond the normal range of motion

·         tripping or falling

·         landing on the foot with increased force

Other injuries that can lead to tendonitis in the ankle or Achilles tendonitis can be caused by:

·         lack of conditioning for the muscles in the leg and foot

·         excess strain on the Achilles tendon, the tendon that connects your calf muscles to your heel

·         bone spurs in the heel that rub on the Achilles tendon

·         untreated flat feet leading to additional stress on the posterior tibialis tendon

Different types of arthritis (inflammation of joints and tissues) can also affect the foot and ankle:

·          

·          symptoms of ankle disorders

 

The symptoms of ankle disorders will vary based on the specific type of injury. Common symptoms include:

·         pain

·         swelling

·         stiffness

·         problems moving the ankle

·         inability to put any weight on the ankle

·         difficulty walking

·         bruising

Tendonitis and Achilles tendonitis may produce similar symptoms, but can be accompanied by:

·         pain along the back of the heel that gets worse throughout the day

·         thickening of the tendon

·         swelling that gets worse with physical activity

·         loud popping sounds at the back of the heel, signaling a ruptured tendon. If this occurs, seek emergency medical attention.

How are ankle disorders diagnose

 

To diagnose an ankle disorder, your doctor will evaluate your symptoms, examine your ankle and foot, and ask about any recent injuries.

To look for bone fractures or tendon tears, imaging tests will be needed. These tests include:

·         X-ray

·         magnetic resonance imaging (MRI)

·         computed tomography (CT) scan

Treatment

 

Treatment will depend on your condition and your symptoms. Treatments can include nonsurgical and surgical options. Nonsurgical options involve:

·         taking pain medications

·         taking medications to reduce swelling and inflammation, like aspirin or ibuprofen

·         resting and elevating your ankle

·         applying ice packs to reduce swelling

·         wearing compression bandages or casts to immobilize your ankle

·         getting cortisone (steroid) injections to reduce pain and swelling

Severe fractures or ruptured tendons may require surgical treatment. Surgical procedures used to treat ankle disorders include:

·         reconstruction to rebuild bones, joints, tendons, and ligaments in your ankle

·         removal of damaged tissue (debridement)

·         lengthening the calf muscles to reduce pressure on your Achilles tendon

·         fusion of the bones in your ankle to make it more stable (arthrodesis)

·         replacement of your ankle joint (arthroplasty)

Long-term outlook for an ankle disorder

 

If you have an ankle disorder, your long-term outlook will depend on the severity of your disorder and the amount of damage to the ankle. It will also depend on whether or not you need surgery.

Ankle sprains are quite common and generally heal within six weeks.

Similar outcomes can be expected if you have an ankle fracture and don’t require surgery.

If your ankle disorder requires surgery, full recovery may take several weeks or months. You may also need physical therapy to help strengthen your ankle. Physical therapy may last as long as 12 months.

Although surgery for most ankle disorders can be helpful for improving mobility, all surgical procedures carry potential risks like the potential for infection and nerve damage.

According to the American Academy of Orthopaedic Surgeons (AAOS), the most common complication is moderate to severe pain following surgery.

How can you prevent ankle disorders

 

Ø  By maintaining good physical fitness,

Ø  Regular exercise is crucial for building strong bones and maintaining good balance.

Ø  Other behaviors that can prevent ankle disorders include:

·         stretching and warming up before and after physical activity

·         wearing comfortable shoes that provide ankle support

·         paying attention to your body’s warning signs — don’t push yourself too hard

Most ankle injuries can be avoided by taking the proper precautions before strenuous exercise.

If you do feel unusual pain in your ankle during physical activity, or suspect an injury, contact your doctor immediately.

Ayurvedic treatments

1-      Leech application.

2-      Dasang lepa.

3-      Gokchuraadi  Guggalu.

4-      Crape bandage

5-      Cold fomentation

6-      Rest

7-      Foot elevation

8-      NSAID

9-      Kaishoor Guggulu