Sandhya Vandanam as Per Shaiva Tantra

Let us understand Sandhya vandanam itself in detail.

Firstly, what is Sandhya?

Sandhya is defined as the junction between two time period. When one period of time overlaps the other, that junction is sandhya.

History Taking for Fracture Case

This article is catered for medical students during the orthopaedics posting. The rationale is to understand the mechanism of fracture and to note relevant points in history to arrive at a proximate diagnosis prior to imaging modalities.

Details of Patient

• Name ( Always address the patient with due respect. Use 'sir', 'mdm', 'gentleman' etc. They are not your servants to be addressed with name directly. )

• Age: It is important to ask for age as it tallies with the mechanism of fracture. An old patient at their 7th decade of life would be having primary osteoporosis. A female patient beyond her 5th decade of life is probably post-menopausal. These are risk factors for pathological fractures. So you would anticipate a low-energy trauma from their history.

*Osteoporosis is the reduction of volume and density of the bones which otherwise have a normal histology. It has primary and secondary causes*

• Occupation 

Relevant Comorbidities

After details, state the relevant comorbidities (eg, patient is a known case of DM II, obesity, osteoporosis, + conditions which demand steroid therapy ). There are two important reasons to this.

1. You want to see if there are risk factors involved. For example, steroid therapy, long history of immobilization, osteomalacia and other bony pathologies can be a risk factor for pathological fractures.

2. You want to access the risk factors for fracture complications. For example, DM, obesity, use of NSAIDS and steroids are recognised risk factors for non-union. A vasculopathy ( eg, sickle cell disease ) is also a risk.

It is not wise to talk about relevant comorbidities after you present your history of presenting illness. Your past medical history is to elaborate on the comorbidities.

Chief Complaint

Then, state the chief complaint

WHAT IS A CHIEF COMPLAINT?

:The REASON for admission. DO NOT WRITE 'FRACTURE'. Fracture is a diagnosis. WRITE a clinical feature. Eg. Pain

Three points to note in chief complaint:

1. ONE clinical feature. Try not to state more than ONE clinical feature. It could be pain, swelling, deformity etc

2. Surface anatomy ( play with 'proximal', 'mid' and 'distal' ). Do not state the bone. Use thigh, knee, leg, ankle, foot, arm, forearm, elbow, wrist, hand, shoulder 

For illustration:

Chief complaint: Pain over right proximal leg for the past 1 day

HOPI – HISTORY OF PRESENTING ILLNESS

(WRITE ONLY WHAT IS RELEVANT TO THE DIAGNOSIS, COMPLICATIONS AND PROGNOSIS. )

Types of fracture:

1. Mechanical / Traumatic. This happens with sheer high energy transfer. Typically involves younger individuals with no significant comorbidity

2. Pathological. This happens with low energy transfer. This is because there is already a pathological weakening of the bone.

3. Stress. This happens with a routine, consistent activity. For example, soldiers who march exert some force on their calcaneum. Imagine performing marching, daily, for years. Exertion of a minimal force, but with sheer consistency eventually shatters the bone.

TRAUMATIC FRACTURE

Make sure you story how the high energy is induced. It can be from a speeding vehicle. Energy is given through force (Force = mass x acceleration). But not all traumatic fracture happens from a high moving vehicle. At times, a slow moving vehicle can induce high energy trauma. How?

Momentum = mass x velocity
Velocity is speed with a direction. It is a vector unit.
So when there is a change in direction there is momentum.
A vehicle may be just moving at 5 km/hr in a taman. But if it takes a turn over say a junction and hits the patient, the change in direction can give velocity. Even the smallest car has considerable mass.
So mass x velocity = that’s a lot of energy to cause fracture. Momentum is 0 when you have only speed with no direction.

Apply inertia in the example of patient getting flung of vehicle. The patient moves at the same speed as the vehicle. The vehicle may come to an absolute stop when it hits something. But the patient will be moving at the constant speed (say 60km/hr). He can be flung and will fall on a hard road. With Newton’s third law, the road will subject back the same force on the patient, causing a probable fracture.

So write some details ascertaining the episode of high energy trauma.

PATHOLOGICAL FRACTURE

If it is pathological fracture, of course first state the comorbidity before chief complain. It is usually a chronic disease which causes bone weakening (eg. Metastatic bone cancer, osteoporosis, multiple myeloma, hyperparathyroidism, osteomalacia etc)

Osteoporosis is the common one you will find but remember, no one really diagnoses this with a bone scan because osteoporosis is asymptomatic. Suspect osteoporosis in elderly patient and those who are post-menopausal.
Pathological fracture usually involves fracture neck of femur in an elderly patient who had slipped and fallen.

Pathological fracture can also come from metastatic cancer. The cancers which spread to bone:

Remember the mnemonic:

PARTICULAR TUMOURS LOVE KILLING BONE

Prostate, thyroid (follicular), lung, kidney (renal adenocarcinoma), breast

These are the tumours which spread to the bone. However, keep in mind that prostate cancer metastasis causes sclerosis ( it actually causing thickening of the bone due to osteoblastic activity ). So in prostate cancers, you do not anticipate pathological fracture.

STRESS FRACTURE

It must come with repetitive action and stress, like repetitive jogging, jumping.

CARDINAL FINDINGS OF FRACTURE

Then, describe the cardinal fracture symptoms. In history taking, you need to sell your diagnosis. So if you want to sell fracture, you have to market the clinical features of it. Never leave them. Describe each one of them in some detail and importantly with anatomical reference. All of them must happen around the same surface anatomy so it indicates a very specific fracture.

• PAIN

• SWELLING

• DEFORMITY

• RESTRICTED RANGE OF MOVEMENT

• NEUROVASCULAR SYMPTOMS

Pain – high pain score? Where? specify.. Proximal thigh? distal part of left leg?

Swelling – same thing – specify area

Deformity – if you can anatomically describe, good. Eg – externally rotated left hip, internally rotated hip etc.. otherwise, at least mention the word 'deformity'

Range of movement – ask if patient was able to ambulate or move the affected joint.

• Hip joint – moves thigh

• Knee joint – moves leg

• Ankle joint – moves foot

• Elbow joint – moves forearm

• Wrist joint – moves hand

• Shoulder joint – moves arm

Neurovascular symptoms – any numbness
Also, ask for evidence of wound or bleeding (open fracture?)

Then, story about the transfer of patient from the site of trauma to the emergency department

The usual management involves:

• Splinting of limb

• Taking xray

• Wound irrigation, debridement for open fracture

• Reduction (open or closed)

• Immobilization (cast, internal fixation, external fixation)

1. Splinting of limb: This is temporary immobilization. When the patient is lying in the site of trauma, like a road, no one knows what's happening within him. No one has Xray vision. We do not know about the severity and stability of a fracture, if at all there is one. Hence, the standard management is to splint the patient's affected limb and to bring him to the hospital. This is to make sure that the affected body part does not undergo movement which can mess things on the inside. If the ambulance arrives, the paramedics will definitely splint the patient with their professional device. If there was no ambulance involved, ask the patient if he was splinted before bringing to the hospital. A splint can be something as simple as an umbrella or tree branch.

2. Ask about imaging. Xray will be the first line to understand the fracture pattern.

3. Wound debridement and irrigation: If there is a wound at the site of the fracture, it accounts for open fracture which can increase complications with infection. So, wound debridement and irrigation will be done. 

4. Reduction: This means to put the broken pieces of bones back to place. Closed reduction means the patient is not cut open in the operation theatre. The bones are brought together in alignment by manipulating, pushing and pulling the limb. Open reduction is when they cut open to directly put the pieces in place. Closed reduction is possible when the fracture is not complicated.

Image: Closed reduction.

Immobilization: After you reduce the bone, you need to immobilize it. Else, they will get displaced again. When you put screws, plates and rods to hold the pieces together, it is called 'internal fixation'. Internal fixation is always done together with open reduction. Hence, the short form ORIF ( open reduction internal fixation ).

Closed reduction can be immobilized with POP cast ( cement in laymen terms ), external fixation, tractions, slabs etc. 

There is a catch here: Not all immobilizations done for closed reduction are permanent ( unlike ORIF which is permanent ).

Patient might be on POP cast or external fixation as a STABILIZATION. This means, patient is just temporarily stabilized until he goes for definitive op (open reduction and internal fixation).

Image: Patient on ex. fix with fasciotomy done for comparment syndrome.

Why do we stabilize patients instead of directly pushing them to the theatre, when in reality, they actually require an op in future?

Not all patients are ready to be sent to the OT directly. For example, there may be contaminated wound. Patient's blood parameters may be crazy and imcompatible for anaesthesia. So, until they correct these issues, the patient's fracture is stabilized. It is not perfectly reduced but it is immobilized to prevent complications.

For example, an external fixation is used when there is extensive soft tissue damage. This allows plastic surgeons and vascular surgeons to attend to the injury through grafting, vascular anastomosis or even wound debridement to optimise patient's condition. 

In ward management

You have to rule out the complications of fracture in ward which can be life threatening. So in history, you rule out symptoms which are classical to some early complications

EARLY COMPLICATIONS TO RULE OUT

• Hypovolemic shock
  -Blood loss usually due to long bone fracture can cause hypovolemic shock

• Fat embolism
  -In ortho, the content of the medulla as fat is very important. In Femur, pelvis and tibia fracture, never forget fat embolism. Fat embolism is a subtype of pulmonary embolism. Just fat leaking from the bone being an embolus. It presents with alteration in mental state (confusion, hallucination etc), respiratory distress and petechia

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• Rhabdomyolysis (crush syndrome)
  -In fracture, you have tissue damage and muscle breakdown. Muscle breakdown releases myoglobin. Excessive myoglobin can cause tubular necrosis of kidney. This will lead to myoglobinuria. It can also cause hyperkalemia (which can lead to cardiac arrest and death!) because potassium is released from lysing muscle cells. So investigations will have findings of high creatine kinase (ck)

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• Compartment syndrome
  - Increased pressure within a compartment in the leg, thigh, forearm due to bleeding /  oedema and even tight cast application. Classically presents as disproportionate pain which does not respond to analgesia.

• Neurological damage- Nerve getting severed by trauma.

• Infection in open fracture-mAsk if the patient is febrile/afebrile

Systemic Review ( Only Relevant )

1. Is patient currently comfortable, alert and conscious under room air? You are ruling out mental status alteration and respiratory distress related to hypovolemic shock and fat embolism

2. Is patient hemodynamically stable (ruling out hypovolemic shock ). You don’t have to mention the BP and HR you measured. If they are normal just say patient is hemodynamically stable).

3. Is there normal urine output with straw yellow colour (check the catheter bag / input output chart or ask patient)? normal output in adult is 0.5ml/kg/hr. It is reduced in hypovolemic shock or AKI. In rhabdomyolysis, urine is dark brown colour.

4. Rule out compartment syndrome where patient will have disproportionate pain. Patient might be in a low pain score, but he might suddenly experience excruciating pain of the lower limbs. The pain is also not relieved by analgesics. This is diagnostic for compartment syndrome. The limb is viable if two-point discrimination sense is still intact.

5. Access nerve injury if numbness is present. In lower limbs, some area of numbness can give u a picture of nerve involved

Sciatic nerve

The sciatic nerve does not have any direct cutaneous functions. It does provide indirect sensory innervation via its terminal branches:

Sciatic nerve ends as the superficial and deep peroneal nerves. The superficial peroneal nerve supplies the entire dorsum of the foot except the first webspace. The deep peroneal nerve supplies sensation to only the first webspace of the foot.

Femoral nerve injury will cause loss of sensation over the anteromedial part of the thigh.

If you can use your anatomy, you can relate the specific part of numbness and guess the involved nerve.

LATE COMPLICATIONS

1. Delayed / non union

So rule out risk factors for this which are:

SMOKING ( mention how many pack year. 1 pack year equates to smoking 1 pack ( 20 sticks ) per day for 1 year )

NSAID (Important, ask on the analgesics they are using, and state it)

STEROIDS

AGE

OBESITY

DIABETES MELLITUS

Non-union can also happen in intraarticular fractures. For fracture healing, the first step is hematoma formation. If the fracture is involving a joint, the hematoma will be absorbed into the synovial fluid. This prevents healing.

2. CPRS ( complex pain regional syndrome )

Image: CPRS evidenced with inflammation and pain out of proportion. Fracture is a known cause for this.

Diagnosis – WRITE ALL COMPONENTS

1.Right or left?

2.Open or closed (wound present at site of fracture)

3.Complete or incomplete

4.Displaced / undisplaced (not applicable for comminuted fracture)

5. Pattern (transverse, comminuted, spiral, oblique)

You can guess the pattern from history.

If there is a crush force, like the limb getting sandwiched between road and vehicle, think about comminuted.

If there was a bending, direct force, think of transverse.

It is usually comminuted in MVA

Anatomical site – Proximal / midshaft / distal?

Intraarticular involvement (if the fracture line is involving with a joint)

Example of a diagnosis:

1.Right open complete displaced transverse fracture of midshaft femur

2. Left closed comminuted fracture of distal femur with intra-articular involvement with knee joint

Applying Vibhuti as Per Shaiva Tantra

The detailed explanation on bhasma application can be found in the snāna vidhiḥ of Kāmika Āgama, Pūrva pāda. For ritual purposes, bhasma must be adorned at at least 16 places.

5 Kala in Shaiva Tantra

Image source: himalayanacademy

This article is an expansion from the writeup on Tattvas in Shaivism. You will not understand this article without reading the mentioned article.

All the tattva-s in Shaivism come from the five kalā-s, which represent different states of consciousness and planes of existence.

Scriptural References for Deepavali

Dīpāvali (दीपावली) comes from the roots:

1. Dīpa (दीप) – From the root dīp (दीप्), which means "to shine" or "to illuminate."

2. Āvali (आवली) – meaning "a row" or "a series".

Vegan Sushi-s For the Delight in Butterworth

Image from Google. Courtesy: Lim Hueh Hueh

The 36 Tattvas of Shaivism

तत्त्वं यद्वस्तुरूपं स्यात्स्वधर्म प्रकटात्मकम्। तत्त्वं वस्तुपदं व्यक्तं स्फुटमाम्नायदर्शनात्॥ 3
tattvaṃ yadvasturūpaṃ syātsvadharma prakaṭātmakam। tattvaṃ vastupadaṃ vyaktaṃ sphuṭamāmnāyadarśanāt॥ 3

Meaning: The principle (tattva) that assumes the form of reality, manifesting its inherent nature, is called tattva. This principle is the manifest, clear expression of the underlying reality, as revealed by the scriptures

यदच्युतं स्वकाद्वृत्तात्ततः शाक्तवशं जगत्। ततमन्येन वा यत्स्यात्तत्तत्त्वं तत्त्वसन्ततौ॥ 4

yadacyutaṃ svakādvṛttāttataḥ śāktavaśaṃ jagat। tatamanyena vā yatsyāt tattattvaṃ tattvasantatau॥ 4

Meaning: When the immutable (acyuta) deviates from its original state and the world falls under the influence of Śakti, whatever form it may take thereafter, that is considered a tattva in the continuum of principles.

Mṛgendra Āgama, (Mataṅga Pārameśvaram Vidyā Pādaḥ 5th Paṭalaḥ) verses 3 & 4

Mystical Kedah and My Nomadic Rituals

Image: Kodiang mountain. Let's go catch a geodude.

Rural Kedah is a world of its own. It is heavily concentrated with mysticism. It is no wonder that this kṣetra finds her unique reference in ancient texts.

Nyasam: The Science of Performing Prana Pratishtha on Self

यत् देवं अर्चयेत् त्वात् तद् देवं आत्म भावन

yat devaṃ arcayet tvāt tad devaṃ ātma bhāvana

Meaning: Whichever deity one worships, he must transform into the deity

Dr. Jayabharati: The Underrated Grandmaster