Case Report

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Journal of Acupuncture Research 2023; 40(3): 272-280

Published online August 31, 2023

https://doi.org/10.13045/jar.2023.00129

© Korean Acupuncture & Moxibustion Medicine Society

Effect of Complex Traditional Korean Medicine Treatment and Rehabilitation on Acetabular Fracture: A Case Report

Young Han Nam , Choong Hyun Han , Young Kyung Kim , Youn Young Choi , Eun Sol Won , Hwa Yeon Ryu , Hyun Lee , Jae Hui Kang

Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, Cheonan, Korea

Correspondence to : Jae Hui Kang
Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, 4, Notaesan-ro, Seobuk-gu, Cheonan 31099, Korea
E-mail: rkd12@hanmail.net

Received: July 8, 2023; Revised: August 2, 2023; Accepted: August 11, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

This report presents the clinical progress of a 50-year-old male diagnosed with a left acetabular fracture and left rib fracture after falling from a height of 3 m. The patient was treated nonsurgically and underwent complex traditional Korean medicine (TKM) treatment and rehabilitation, including acupuncture, electroacupuncture, pharmacopuncture, bee venom, herbal medicine, physiotherapy, and moxibustion. Patient progress was assessed using the numerical rating scale (NRS), manual muscle test (MMT), and modified Harris Hip Score (mHHS). During 113 days of hospitalization, the NRS score decreased from 7 to 3, and the MMT grade increased to normal in the hip, knee, and ankle joints. The mHHS score increased from 26 to 99 points. Radiographs and computed tomography scans of the left acetabulum were obtained periodically, and fracture union was successfully achieved. To our knowledge, this is the first case report of complex TKM treatment and rehabilitation of acetabular fractures.

Keywords Acupuncture; Bee venom; Hip fracture; Korean traditional medicine

Acetabular fractures are rare injuries and constitute 18% of all pelvic fractures [1], with an incidence rate of approximately 3 per 100,000 per year worldwide [2,3]. They are usually caused by high-energy injuries, such as traffic accidents or falls [3]. Acetabular fractures are caused by the direct impact of the femoral head on the articular surface of the acetabulum. The force on the femoral head can be transmitted in any direction through the trochanter and the femoral neck along the long axis of the femoral shaft. Therefore, the classification of fractures varies depending on the hip joint position during trauma [4].

Acetabular fractures can be treated conservatively or surgically. The treatment must be decided carefully, considering the fracture pattern, patient’s mental state, age, and accompanying injuries [5]. In traditional Korean medicine (TKM) hospitals, conservative treatment and postoperative rehabilitation are actively performed for patients with pelvic fractures [6,7]. However, to our knowledge, no study has reported using TKM treatment from the acute to the rehabilitation stage of acetabular fractures. In this report, we present a case of a patient who received complex TKM treatment and rehabilitation without surgery.

1. Patient

Male, 50 years old.

1) Chief complaint

Left hip pain, left elbow pain, and left flank pain.

2) Past medical history

The patient underwent lumbar intervertebral disc herniation surgery in 2017 and 2022 and cholecystectomy in 2023. He was diagnosed with diabetes in 2020 and was taking prescribed medications.

3) Present illness

On March 9, 2023, the patient fell from 3 m height and injured the left half of his body. He was transferred to Hyosung Hospital, and radiography and computed tomography (CT) were performed. The patient was diagnosed with a left acetabular fracture and left rib fractures (5, 6, 7, and 8th). The left elbow was intact. On March 10, 2023, he was transferred to Soonchunhyang University Hospital, and the staff reported that surgery was not required for the left acetabular fracture.

4) Treatment duration

March 10, 2023 to June 30, 2023 (113 days of hospitalization).

5) Radiology

Pelvis CT was performed on March 9 and April 21, 2023 (Fig. 1). Pelvis 3 dimension CT was performed on March 9, 2023 (Fig. 2). Left hip radiography was performed on March 9, March 17, April 7, May 13, June 2, and June 23, 2023 (Figs. 3, 4).

Fig. 1. (A) Pelvis computed tomography (CT) was performed right after the injury (March 9, 2023), and the patient was diagnosed with a left acetabular fracture. (B) Pelvis CT was performed 6 weeks after the injury (April 21, 2023).
Fig. 2. Pelvis 3 dimension computed tomography was performed right after the injury (March 9, 2023). The image shows fracture on the anterior acetabulum (green arrow).
Fig. 3. Left hip radiography, anteroposterior view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.
Fig. 4. Left hip radiography, lateral view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.
6) Patient protection policy on patient information use

To protect the patient’s personal information, medical records were obtained from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (No. DJUMC-2023-BM-08).

2. Treatment

1) Acupuncture

Stainless steel needles 0.25 × 30 mm and 0.30 × 40 mm (Dongbang Medical Co., Ltd.) were used. Acupuncture was performed unilaterally at GB29, GB30, GB31, GB32, GB33, ST30, ST31, ST32, ST34, ST36, BL23, BL36, and tender points on the gluteus muscle, hamstrings, gastrocnemius, left ribs, and left elbow twice daily for 15 minutes. Electrical stimulation (2 Hz) was applied to GB29–ST32 and GB30–GB31 using an STN-330 (Stratek) in a continuous wave. The current intensity was set at a tolerable level.

2) Pharmacopuncture

Aconitum ciliare Decaisne pharmacopuncture (ACDP) (Korean Pharmacopuncture Institute) was administered once daily from March 13 to March 24, 2023. A 0.2 mL dose was injected into GB29, GB30, GB31, BL23, and BL36. A 1.0 mL disposable syringe and needle were used for injections (30 G, 12.7 mm needle; Jungrim Medical).

3) Bee venom

Before administering the bee venom (BV) treatment, informed consent was obtained from the patient due to the potential risks of using BV, such as anaphylaxis. A hypersensitivity skin test to BV (1:20,000, 0.1 mL; Korean Pharmacopuncture Association) was performed, and the result was negative. Treatment was administered unilaterally at GB29, GB30, GB31, BL23, and BL36. The concentration of BV was increased in the order of 1:20,000, 1:10,000, 1:5,000, and 1:2,000, and sweet bee venom (SBV; Kirin Korean Medicine Industrial Institute) 10%, SBV 20%, and SBV 50% were also used for intramuscular (IM) injection. If a hypersensitivity reaction did not occur, the injected volume was increased with each treatment (Table 1).

Table 1 . Bee venom injection

DateBee venom concentrationVolume (mL)
March 25, 2023SBV 10%0.5
March 27, 2023SBV 10%0.5
March 29, 2023SBV 20%0.5
March 31, 2023SBV 20%0.5
April 3, 2023SBV 20%0.5
April 5, 2023SBV 20%0.5
April 7, 2023SBV 20%0.5
April 10, 2023SBV 50%0.5
April 12, 2023SBV 50%0.7
April 14, 202320,000:10.5
April 17, 202310,000:10.5
April 19, 20235,000:10.5
April 21, 20235,000:11
April 24, 20235,000:11
April 26, 20235,000:11
April 28, 20235,000:11
May 1, 20232,000:10.4
May 3, 20232,000:10.6

SBV, sweet bee venom.


4) Herbal medicine

The patient took herbal medicines 3 times daily. Hwanggihwalhyeol-tang, Dodamhwalhyeol-tang, and Gamigungi-tang were prescribed (Table 2). Palmul-tang soft extract and Gumiganghwal-tang soft extract were also prescribed (Table 3).

Table 2 . Herbal composition of 3 herbal medications for daily dosage

Hwanggihwalhyeol-tang (March 10, 2023–March 15, 2023)Amount (g)Dodamhwalhyeol-tang (March 15, 2023–April 7, 2023)Amount (g)Gamigungi-tang (April 7, 2023–May 7, 2023)Amount (g)
Atractylodis rhizoma18Cyperi rhizoma16Angelica gigantis radix40
Angelica gigantis radix18Pinelliae tuber12Cnidii rhizoma40
Cnidii rhizoma18Crataegi fructus12Astragali radix16
Astragali radix18Raphani semen12Ginseng radix16
Cibotii rhizoma18Salviae miltiorrhizae radix12Lycii fructus16
Lonicerae flos18Tribuli fructus8Codonopsis pilosulae radix8
Typhae pollen18Poria sclerotium8Cuscutae semen8
Trogopterorum faeces18Puerariae radix8Dipsaci radix8
Lycopi herba18Uncariae ramulus et uncus8Dendrobii herba8
Spatholobi caulis18Angelica gigantis radix8
Smilacis rhizoma18Platycodonnis radix8
Citri unshius pericarpium12Aurantii fructus immaturus8
Glycyrrhizae radix12Acori graminei rhizoma24
Poria sclerotium12Aucklandiae radix6
Eucommiae cortex12Persicae semen6
Dipsaci radix12Carthami flos6
Achyranthis radix12Cnidii rhizoma6
Chaenomelis fructus12Menthae herba4
Persicae semen12Scorpio4
Carthami flos12Glycyrrhizae radix4
Corydalis tuber12Lumbricus24
Forsythiae fructus12Citri unshius pericarpium12
Massa medicata fermentata12
Amomi fructus12
Cyperi rhizoma12
Ziniberis rhizoma6
Cinnamomi ramulus6
Scutellariae radix6
Liriopis seu ophiopogonis tuber6

Table 3 . Soft extract herbal medications for daily dosage

Palmul-tang soft extract (May 8, 2023–May 25, 2023)Amount (g)Gumiganghwal-tang soft extract (May 25, 2023–June 30, 2023)Amount (g)
Poria sclerotium0.675Osteroici seu notopterygii radix et rhizoma1.9740
Ginseng radix1.260Saposhnikoviae radix2.0304
Atractylodis rhizoma1.485Cnidii rhizoma1.9350
Glycyrrhizae radix1.980Angelicae dahuricae radix1.1250
Rehmanniae radix preparata2.160Atractylodis rhizoma1.3950
Paeoniae radix alba1.485Scutellariae radix2.6550
Cnidii rhizoma1.935Rehmanniae radix1.0800
Angelica gigantis radix1.485Asiasari radix et rhizoma0.4914
Glycyrrhizae radix0.8316

5) Physiotherapy

Transcutaneous electrical nerve stimulation was applied daily for 15 minutes to the left gluteal region to reduce pain.

6) Moxibustion

Indirect electric moxibustion therapy (Technoscience) was applied twice daily at GB 29, GB 30, GB 31, GB 32, and ST 31.

7) Rehabilitation training

Ankle pumps were performed by himself 30 times daily to prevent muscle contracture. From April 22, straight leg raise, and heel slide exercises were performed by himself 30 times daily. Quadriceps, adductor, abductor, and hamstrings isometric exercises were performed 3 times weekly for 15 minutes under a Korean medicine doctor’s guidance.

3. Evaluation

1) Numerical rating scale

The numerical rating scale (NRS) was used to assess subjective pain in the left hip. The NRS score ranges from 0 to 10, with 0 indicating no pain and 10 indicating maximum pain.

2) Manual muscle test

The manual muscle test (MMT) was used to evaluate muscle strength (Table 4). To prevent damage to the fracture site, the MMT grades of the hip, knee, and ankle joints were first assessed on April 22. Then, the MMT grades of the hip, knee, and ankle joints were assessed weekly.

Table 4 . Manual muscle test

GradeCategoryFunction of the muscle
Grade 0Zero (Z)No visible or palpable muscle contraction.
Grade 1Trace (T)Feel contraction with palpation; no visible movement.
Grade 2−P−Less than full ROM in gravity eliminated plane.
Grade 2Poor (P)Full ROM in gravity eliminated plane with no resistance.
Grade 2+P+Full ROM in gravity eliminated plane, breaks upon minimum resistance.
Grade 3−F−Less than full ROM against gravity, but more than 50%.
Grade 3Fair (F)Full ROM against gravity, with no resistance.
Grade 3+F+Full ROM against gravity, breaks upon minimum resistance.
Grade 4Good (G)Full ROM against gravity with moderate resistance.
Grade 5Normal (N)Full ROM against gravity with maximum resistance.

ROM, range of motion.


3) Modified Harris Hip Score

The Harris Hip Score (HHS) is a commonly used hip questionnaire with high validity and reliability [8]. The modified HHS (mHHS) was developed to adjust the HHS to evaluate acetabular fracture treatment [9]. The maximum mHHS score was 120 points, comprising pain (0–60 points), function (0–42 points), relative strength (0–10 points), and relative range of motion (0–8 points) (Appendix A). The mHHS was assessed on March 10, March 30, April 21, May 12, June 2, June 23, and June 30, 2023.

4. Patient’s progress during treatment

On admission, the patient complained of left hip pain of NRS 7. The pain in the gluteal region was the most severe. Therefore, it was difficult for him to roll over or defecate. Two weeks after the start of treatment, the patient was able to sleep without pain, and it became easier for him to roll over and defecate. At discharge, the left hip pain decreased to NRS 3 (Fig. 5). The MMT grades of the left hip, knee, and ankle joints increased from F+ to N (Table 5). The mHHS score increased from 26 to 99 points (Fig. 6). Upon admission, the patient underwent absolute bed rest. On April 22, after the fracture site healing was confirmed on CT images, he began ambulating with 2 crutches or a walker. At discharge, he was able to walk unassisted for more than 20 minutes.

Table 5 . Manual muscle test results

MovementApril 22, 2023April 28, 2023May 4, 2023May 12, 2023May 19, 2023May 26, 2023June 2, 2023June 9, 2023June 16, 2023June 23, 2023June 30, 2023
Hip flexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Hip extensionN/F+N/F+N/F+N/F+N/NN/NN/NN/NN/NN/NN/N
Knee flexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Knee extensionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Ankle dorsiflexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Ankle plantarflexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N

N, normal; F, fair; G, good.


Fig. 5. Changes in NRS from March 9 to June 30. NRS, numerical rating scale; Adm., on admission; D/C, on discharge.
Fig. 6. Changes in the mHHS score from March 10 to June 30. On admission, the patient was not able to walk. On discharge, the patient was able to walk for more than 20 minutes without support. mHHS, modified Harris Hip Score.

As acetabular fractures are caused by high-energy injuries, other body parts often sustain damage [10]. This may delay treatment. Moreover, surgery is difficult because the acetabulum is located deep in the body [11].

Accurate classification is essential for determining the treatment strategy for acetabular fractures [4]. According to the Judet and Letournel classification, elementary fractures include the posterior wall, posterior column, anterior wall, anterior column, or transverse fractures. Associated fractures are combinations of 2 or more elementary fractures [5,12].

Although many acetabular fractures are treated surgically, conservative treatment is a viable option for some patients [13,14]. Absolute bed rest and skeletal traction are performed to keep the femoral head away from the acetabular fracture fragments. Conservative treatment includes early mobilization with limited and progressive weight-bearing. Typically, 10–20 kg of toe-touch weight- bearing is performed for the first 4–6 weeks, followed by progression to full weight-bearing at 8–12 weeks [5]. Matta et al. [15] reported that 75% of patients with acetabular fractures in the conservative treatment group showed excellent or good clinical results.

In this report, the patient was diagnosed with an acetabular anterior wall fracture. Although the fall had a significant impact on the patient, the acetabular fracture was stable. Therefore, TKM was an effective option for pain reduction and functional rehabilitation.

Acupuncture with electrical stimulation is mainly applied to the gallbladder and bladder meridian acupoint to reduce pain and accelerate bone healing [16,17]. ACDP and BV were injected IM into the gallbladder and bladder meridian acupoints. ACDP accelerates peripheral blood circulation and reduces neuropathic pain [18]. BV reduces musculoskeletal pain and has anti-inflammatory effects [19]. Hwanggihwalhyeol-tang and Dodamhwalhyeol-tang were prescribed to reduce pain and promote blood circulation. Gamigungi-tang was prescribed to promote fracture union once the pain started to decrease. Palmul-tang soft extract was prescribed to strengthen bones and muscles, and Gumiganghwal-tang soft extract was prescribed to relieve muscle pain during rehabilitation.

To our knowledge, this is the first study to report the treatment of acetabular fractures using TKM. The patient’s pain was effectively reduced without analgesics during the acute stage, and the fracture site healed successfully without dislocation or complications. Although comparisons are difficult due to the diversity of fracture patterns, the TKM treatment delivered here showed comparable results to those of conventional conservative treatment. However, this study had some limitations. It reported a single case, and several complex treatments were performed simultaneously. Therefore, the effect of each treatment could not be determined. Thus, further research on the TKM treatment of acetabular fractures is required.

Conceptualization: YHN. Methodology: YHN. Formal investigation: YHN. Data analysis: YHN. Writing – original draft: YHN. Writing – review & editing: All authors.

This study was exempt from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (IRB No. DJUMC-2023-BM-08).

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Article

Case Report

Journal of Acupuncture Research 2023; 40(3): 272-280

Published online August 31, 2023 https://doi.org/10.13045/jar.2023.00129

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

Effect of Complex Traditional Korean Medicine Treatment and Rehabilitation on Acetabular Fracture: A Case Report

Young Han Nam , Choong Hyun Han , Young Kyung Kim , Youn Young Choi , Eun Sol Won , Hwa Yeon Ryu , Hyun Lee , Jae Hui Kang

Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, Cheonan, Korea

Correspondence to:Jae Hui Kang
Department of Acupuncture and Moxibustion Medicine, College of Korean Medicine, Daejeon University, 4, Notaesan-ro, Seobuk-gu, Cheonan 31099, Korea
E-mail: rkd12@hanmail.net

Received: July 8, 2023; Revised: August 2, 2023; Accepted: August 11, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

This report presents the clinical progress of a 50-year-old male diagnosed with a left acetabular fracture and left rib fracture after falling from a height of 3 m. The patient was treated nonsurgically and underwent complex traditional Korean medicine (TKM) treatment and rehabilitation, including acupuncture, electroacupuncture, pharmacopuncture, bee venom, herbal medicine, physiotherapy, and moxibustion. Patient progress was assessed using the numerical rating scale (NRS), manual muscle test (MMT), and modified Harris Hip Score (mHHS). During 113 days of hospitalization, the NRS score decreased from 7 to 3, and the MMT grade increased to normal in the hip, knee, and ankle joints. The mHHS score increased from 26 to 99 points. Radiographs and computed tomography scans of the left acetabulum were obtained periodically, and fracture union was successfully achieved. To our knowledge, this is the first case report of complex TKM treatment and rehabilitation of acetabular fractures.

Keywords: Acupuncture, Bee venom, Hip fracture, Korean traditional medicine

INTRODUCTION

Acetabular fractures are rare injuries and constitute 18% of all pelvic fractures [1], with an incidence rate of approximately 3 per 100,000 per year worldwide [2,3]. They are usually caused by high-energy injuries, such as traffic accidents or falls [3]. Acetabular fractures are caused by the direct impact of the femoral head on the articular surface of the acetabulum. The force on the femoral head can be transmitted in any direction through the trochanter and the femoral neck along the long axis of the femoral shaft. Therefore, the classification of fractures varies depending on the hip joint position during trauma [4].

Acetabular fractures can be treated conservatively or surgically. The treatment must be decided carefully, considering the fracture pattern, patient’s mental state, age, and accompanying injuries [5]. In traditional Korean medicine (TKM) hospitals, conservative treatment and postoperative rehabilitation are actively performed for patients with pelvic fractures [6,7]. However, to our knowledge, no study has reported using TKM treatment from the acute to the rehabilitation stage of acetabular fractures. In this report, we present a case of a patient who received complex TKM treatment and rehabilitation without surgery.

CASE REPORT

1. Patient

Male, 50 years old.

1) Chief complaint

Left hip pain, left elbow pain, and left flank pain.

2) Past medical history

The patient underwent lumbar intervertebral disc herniation surgery in 2017 and 2022 and cholecystectomy in 2023. He was diagnosed with diabetes in 2020 and was taking prescribed medications.

3) Present illness

On March 9, 2023, the patient fell from 3 m height and injured the left half of his body. He was transferred to Hyosung Hospital, and radiography and computed tomography (CT) were performed. The patient was diagnosed with a left acetabular fracture and left rib fractures (5, 6, 7, and 8th). The left elbow was intact. On March 10, 2023, he was transferred to Soonchunhyang University Hospital, and the staff reported that surgery was not required for the left acetabular fracture.

4) Treatment duration

March 10, 2023 to June 30, 2023 (113 days of hospitalization).

5) Radiology

Pelvis CT was performed on March 9 and April 21, 2023 (Fig. 1). Pelvis 3 dimension CT was performed on March 9, 2023 (Fig. 2). Left hip radiography was performed on March 9, March 17, April 7, May 13, June 2, and June 23, 2023 (Figs. 3, 4).

Figure 1. (A) Pelvis computed tomography (CT) was performed right after the injury (March 9, 2023), and the patient was diagnosed with a left acetabular fracture. (B) Pelvis CT was performed 6 weeks after the injury (April 21, 2023).
Figure 2. Pelvis 3 dimension computed tomography was performed right after the injury (March 9, 2023). The image shows fracture on the anterior acetabulum (green arrow).
Figure 3. Left hip radiography, anteroposterior view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.
Figure 4. Left hip radiography, lateral view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.
6) Patient protection policy on patient information use

To protect the patient’s personal information, medical records were obtained from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (No. DJUMC-2023-BM-08).

2. Treatment

1) Acupuncture

Stainless steel needles 0.25 × 30 mm and 0.30 × 40 mm (Dongbang Medical Co., Ltd.) were used. Acupuncture was performed unilaterally at GB29, GB30, GB31, GB32, GB33, ST30, ST31, ST32, ST34, ST36, BL23, BL36, and tender points on the gluteus muscle, hamstrings, gastrocnemius, left ribs, and left elbow twice daily for 15 minutes. Electrical stimulation (2 Hz) was applied to GB29–ST32 and GB30–GB31 using an STN-330 (Stratek) in a continuous wave. The current intensity was set at a tolerable level.

2) Pharmacopuncture

Aconitum ciliare Decaisne pharmacopuncture (ACDP) (Korean Pharmacopuncture Institute) was administered once daily from March 13 to March 24, 2023. A 0.2 mL dose was injected into GB29, GB30, GB31, BL23, and BL36. A 1.0 mL disposable syringe and needle were used for injections (30 G, 12.7 mm needle; Jungrim Medical).

3) Bee venom

Before administering the bee venom (BV) treatment, informed consent was obtained from the patient due to the potential risks of using BV, such as anaphylaxis. A hypersensitivity skin test to BV (1:20,000, 0.1 mL; Korean Pharmacopuncture Association) was performed, and the result was negative. Treatment was administered unilaterally at GB29, GB30, GB31, BL23, and BL36. The concentration of BV was increased in the order of 1:20,000, 1:10,000, 1:5,000, and 1:2,000, and sweet bee venom (SBV; Kirin Korean Medicine Industrial Institute) 10%, SBV 20%, and SBV 50% were also used for intramuscular (IM) injection. If a hypersensitivity reaction did not occur, the injected volume was increased with each treatment (Table 1).

Table 1 . Bee venom injection.

DateBee venom concentrationVolume (mL)
March 25, 2023SBV 10%0.5
March 27, 2023SBV 10%0.5
March 29, 2023SBV 20%0.5
March 31, 2023SBV 20%0.5
April 3, 2023SBV 20%0.5
April 5, 2023SBV 20%0.5
April 7, 2023SBV 20%0.5
April 10, 2023SBV 50%0.5
April 12, 2023SBV 50%0.7
April 14, 202320,000:10.5
April 17, 202310,000:10.5
April 19, 20235,000:10.5
April 21, 20235,000:11
April 24, 20235,000:11
April 26, 20235,000:11
April 28, 20235,000:11
May 1, 20232,000:10.4
May 3, 20232,000:10.6

SBV, sweet bee venom..


4) Herbal medicine

The patient took herbal medicines 3 times daily. Hwanggihwalhyeol-tang, Dodamhwalhyeol-tang, and Gamigungi-tang were prescribed (Table 2). Palmul-tang soft extract and Gumiganghwal-tang soft extract were also prescribed (Table 3).

Table 2 . Herbal composition of 3 herbal medications for daily dosage.

Hwanggihwalhyeol-tang (March 10, 2023–March 15, 2023)Amount (g)Dodamhwalhyeol-tang (March 15, 2023–April 7, 2023)Amount (g)Gamigungi-tang (April 7, 2023–May 7, 2023)Amount (g)
Atractylodis rhizoma18Cyperi rhizoma16Angelica gigantis radix40
Angelica gigantis radix18Pinelliae tuber12Cnidii rhizoma40
Cnidii rhizoma18Crataegi fructus12Astragali radix16
Astragali radix18Raphani semen12Ginseng radix16
Cibotii rhizoma18Salviae miltiorrhizae radix12Lycii fructus16
Lonicerae flos18Tribuli fructus8Codonopsis pilosulae radix8
Typhae pollen18Poria sclerotium8Cuscutae semen8
Trogopterorum faeces18Puerariae radix8Dipsaci radix8
Lycopi herba18Uncariae ramulus et uncus8Dendrobii herba8
Spatholobi caulis18Angelica gigantis radix8
Smilacis rhizoma18Platycodonnis radix8
Citri unshius pericarpium12Aurantii fructus immaturus8
Glycyrrhizae radix12Acori graminei rhizoma24
Poria sclerotium12Aucklandiae radix6
Eucommiae cortex12Persicae semen6
Dipsaci radix12Carthami flos6
Achyranthis radix12Cnidii rhizoma6
Chaenomelis fructus12Menthae herba4
Persicae semen12Scorpio4
Carthami flos12Glycyrrhizae radix4
Corydalis tuber12Lumbricus24
Forsythiae fructus12Citri unshius pericarpium12
Massa medicata fermentata12
Amomi fructus12
Cyperi rhizoma12
Ziniberis rhizoma6
Cinnamomi ramulus6
Scutellariae radix6
Liriopis seu ophiopogonis tuber6

Table 3 . Soft extract herbal medications for daily dosage.

Palmul-tang soft extract (May 8, 2023–May 25, 2023)Amount (g)Gumiganghwal-tang soft extract (May 25, 2023–June 30, 2023)Amount (g)
Poria sclerotium0.675Osteroici seu notopterygii radix et rhizoma1.9740
Ginseng radix1.260Saposhnikoviae radix2.0304
Atractylodis rhizoma1.485Cnidii rhizoma1.9350
Glycyrrhizae radix1.980Angelicae dahuricae radix1.1250
Rehmanniae radix preparata2.160Atractylodis rhizoma1.3950
Paeoniae radix alba1.485Scutellariae radix2.6550
Cnidii rhizoma1.935Rehmanniae radix1.0800
Angelica gigantis radix1.485Asiasari radix et rhizoma0.4914
Glycyrrhizae radix0.8316

5) Physiotherapy

Transcutaneous electrical nerve stimulation was applied daily for 15 minutes to the left gluteal region to reduce pain.

6) Moxibustion

Indirect electric moxibustion therapy (Technoscience) was applied twice daily at GB 29, GB 30, GB 31, GB 32, and ST 31.

7) Rehabilitation training

Ankle pumps were performed by himself 30 times daily to prevent muscle contracture. From April 22, straight leg raise, and heel slide exercises were performed by himself 30 times daily. Quadriceps, adductor, abductor, and hamstrings isometric exercises were performed 3 times weekly for 15 minutes under a Korean medicine doctor’s guidance.

3. Evaluation

1) Numerical rating scale

The numerical rating scale (NRS) was used to assess subjective pain in the left hip. The NRS score ranges from 0 to 10, with 0 indicating no pain and 10 indicating maximum pain.

2) Manual muscle test

The manual muscle test (MMT) was used to evaluate muscle strength (Table 4). To prevent damage to the fracture site, the MMT grades of the hip, knee, and ankle joints were first assessed on April 22. Then, the MMT grades of the hip, knee, and ankle joints were assessed weekly.

Table 4 . Manual muscle test.

GradeCategoryFunction of the muscle
Grade 0Zero (Z)No visible or palpable muscle contraction.
Grade 1Trace (T)Feel contraction with palpation; no visible movement.
Grade 2−P−Less than full ROM in gravity eliminated plane.
Grade 2Poor (P)Full ROM in gravity eliminated plane with no resistance.
Grade 2+P+Full ROM in gravity eliminated plane, breaks upon minimum resistance.
Grade 3−F−Less than full ROM against gravity, but more than 50%.
Grade 3Fair (F)Full ROM against gravity, with no resistance.
Grade 3+F+Full ROM against gravity, breaks upon minimum resistance.
Grade 4Good (G)Full ROM against gravity with moderate resistance.
Grade 5Normal (N)Full ROM against gravity with maximum resistance.

ROM, range of motion..


3) Modified Harris Hip Score

The Harris Hip Score (HHS) is a commonly used hip questionnaire with high validity and reliability [8]. The modified HHS (mHHS) was developed to adjust the HHS to evaluate acetabular fracture treatment [9]. The maximum mHHS score was 120 points, comprising pain (0–60 points), function (0–42 points), relative strength (0–10 points), and relative range of motion (0–8 points) (Appendix A). The mHHS was assessed on March 10, March 30, April 21, May 12, June 2, June 23, and June 30, 2023.

4. Patient’s progress during treatment

On admission, the patient complained of left hip pain of NRS 7. The pain in the gluteal region was the most severe. Therefore, it was difficult for him to roll over or defecate. Two weeks after the start of treatment, the patient was able to sleep without pain, and it became easier for him to roll over and defecate. At discharge, the left hip pain decreased to NRS 3 (Fig. 5). The MMT grades of the left hip, knee, and ankle joints increased from F+ to N (Table 5). The mHHS score increased from 26 to 99 points (Fig. 6). Upon admission, the patient underwent absolute bed rest. On April 22, after the fracture site healing was confirmed on CT images, he began ambulating with 2 crutches or a walker. At discharge, he was able to walk unassisted for more than 20 minutes.

Table 5 . Manual muscle test results.

MovementApril 22, 2023April 28, 2023May 4, 2023May 12, 2023May 19, 2023May 26, 2023June 2, 2023June 9, 2023June 16, 2023June 23, 2023June 30, 2023
Hip flexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Hip extensionN/F+N/F+N/F+N/F+N/NN/NN/NN/NN/NN/NN/N
Knee flexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Knee extensionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Ankle dorsiflexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Ankle plantarflexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N

N, normal; F, fair; G, good..


Figure 5. Changes in NRS from March 9 to June 30. NRS, numerical rating scale; Adm., on admission; D/C, on discharge.
Figure 6. Changes in the mHHS score from March 10 to June 30. On admission, the patient was not able to walk. On discharge, the patient was able to walk for more than 20 minutes without support. mHHS, modified Harris Hip Score.

DISCUSSION

As acetabular fractures are caused by high-energy injuries, other body parts often sustain damage [10]. This may delay treatment. Moreover, surgery is difficult because the acetabulum is located deep in the body [11].

Accurate classification is essential for determining the treatment strategy for acetabular fractures [4]. According to the Judet and Letournel classification, elementary fractures include the posterior wall, posterior column, anterior wall, anterior column, or transverse fractures. Associated fractures are combinations of 2 or more elementary fractures [5,12].

Although many acetabular fractures are treated surgically, conservative treatment is a viable option for some patients [13,14]. Absolute bed rest and skeletal traction are performed to keep the femoral head away from the acetabular fracture fragments. Conservative treatment includes early mobilization with limited and progressive weight-bearing. Typically, 10–20 kg of toe-touch weight- bearing is performed for the first 4–6 weeks, followed by progression to full weight-bearing at 8–12 weeks [5]. Matta et al. [15] reported that 75% of patients with acetabular fractures in the conservative treatment group showed excellent or good clinical results.

In this report, the patient was diagnosed with an acetabular anterior wall fracture. Although the fall had a significant impact on the patient, the acetabular fracture was stable. Therefore, TKM was an effective option for pain reduction and functional rehabilitation.

Acupuncture with electrical stimulation is mainly applied to the gallbladder and bladder meridian acupoint to reduce pain and accelerate bone healing [16,17]. ACDP and BV were injected IM into the gallbladder and bladder meridian acupoints. ACDP accelerates peripheral blood circulation and reduces neuropathic pain [18]. BV reduces musculoskeletal pain and has anti-inflammatory effects [19]. Hwanggihwalhyeol-tang and Dodamhwalhyeol-tang were prescribed to reduce pain and promote blood circulation. Gamigungi-tang was prescribed to promote fracture union once the pain started to decrease. Palmul-tang soft extract was prescribed to strengthen bones and muscles, and Gumiganghwal-tang soft extract was prescribed to relieve muscle pain during rehabilitation.

To our knowledge, this is the first study to report the treatment of acetabular fractures using TKM. The patient’s pain was effectively reduced without analgesics during the acute stage, and the fracture site healed successfully without dislocation or complications. Although comparisons are difficult due to the diversity of fracture patterns, the TKM treatment delivered here showed comparable results to those of conventional conservative treatment. However, this study had some limitations. It reported a single case, and several complex treatments were performed simultaneously. Therefore, the effect of each treatment could not be determined. Thus, further research on the TKM treatment of acetabular fractures is required.

AUTHOR CONTRIBUTIONS

Conceptualization: YHN. Methodology: YHN. Formal investigation: YHN. Data analysis: YHN. Writing – original draft: YHN. Writing – review & editing: All authors.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

FUNDING

None.

ETHICAL STATEMENT

This study was exempt from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (IRB No. DJUMC-2023-BM-08).

Fig 1.

Figure 1.(A) Pelvis computed tomography (CT) was performed right after the injury (March 9, 2023), and the patient was diagnosed with a left acetabular fracture. (B) Pelvis CT was performed 6 weeks after the injury (April 21, 2023).
Journal of Acupuncture Research 2023; 40: 272-280https://doi.org/10.13045/jar.2023.00129

Fig 2.

Figure 2.Pelvis 3 dimension computed tomography was performed right after the injury (March 9, 2023). The image shows fracture on the anterior acetabulum (green arrow).
Journal of Acupuncture Research 2023; 40: 272-280https://doi.org/10.13045/jar.2023.00129

Fig 3.

Figure 3.Left hip radiography, anteroposterior view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.
Journal of Acupuncture Research 2023; 40: 272-280https://doi.org/10.13045/jar.2023.00129

Fig 4.

Figure 4.Left hip radiography, lateral view. (A) March 9, 2023; (B) March 17, 2023; (C) April 7, 2023; (D) May 13, 2023; (E) June 2, 2023; (F) June 23, 2023. A comparison between (A) and (F) shows the progress of ossification at the fracture site.
Journal of Acupuncture Research 2023; 40: 272-280https://doi.org/10.13045/jar.2023.00129

Fig 5.

Figure 5.Changes in NRS from March 9 to June 30. NRS, numerical rating scale; Adm., on admission; D/C, on discharge.
Journal of Acupuncture Research 2023; 40: 272-280https://doi.org/10.13045/jar.2023.00129

Fig 6.

Figure 6.Changes in the mHHS score from March 10 to June 30. On admission, the patient was not able to walk. On discharge, the patient was able to walk for more than 20 minutes without support. mHHS, modified Harris Hip Score.
Journal of Acupuncture Research 2023; 40: 272-280https://doi.org/10.13045/jar.2023.00129

Table 1 . Bee venom injection.

DateBee venom concentrationVolume (mL)
March 25, 2023SBV 10%0.5
March 27, 2023SBV 10%0.5
March 29, 2023SBV 20%0.5
March 31, 2023SBV 20%0.5
April 3, 2023SBV 20%0.5
April 5, 2023SBV 20%0.5
April 7, 2023SBV 20%0.5
April 10, 2023SBV 50%0.5
April 12, 2023SBV 50%0.7
April 14, 202320,000:10.5
April 17, 202310,000:10.5
April 19, 20235,000:10.5
April 21, 20235,000:11
April 24, 20235,000:11
April 26, 20235,000:11
April 28, 20235,000:11
May 1, 20232,000:10.4
May 3, 20232,000:10.6

SBV, sweet bee venom..


Table 2 . Herbal composition of 3 herbal medications for daily dosage.

Hwanggihwalhyeol-tang (March 10, 2023–March 15, 2023)Amount (g)Dodamhwalhyeol-tang (March 15, 2023–April 7, 2023)Amount (g)Gamigungi-tang (April 7, 2023–May 7, 2023)Amount (g)
Atractylodis rhizoma18Cyperi rhizoma16Angelica gigantis radix40
Angelica gigantis radix18Pinelliae tuber12Cnidii rhizoma40
Cnidii rhizoma18Crataegi fructus12Astragali radix16
Astragali radix18Raphani semen12Ginseng radix16
Cibotii rhizoma18Salviae miltiorrhizae radix12Lycii fructus16
Lonicerae flos18Tribuli fructus8Codonopsis pilosulae radix8
Typhae pollen18Poria sclerotium8Cuscutae semen8
Trogopterorum faeces18Puerariae radix8Dipsaci radix8
Lycopi herba18Uncariae ramulus et uncus8Dendrobii herba8
Spatholobi caulis18Angelica gigantis radix8
Smilacis rhizoma18Platycodonnis radix8
Citri unshius pericarpium12Aurantii fructus immaturus8
Glycyrrhizae radix12Acori graminei rhizoma24
Poria sclerotium12Aucklandiae radix6
Eucommiae cortex12Persicae semen6
Dipsaci radix12Carthami flos6
Achyranthis radix12Cnidii rhizoma6
Chaenomelis fructus12Menthae herba4
Persicae semen12Scorpio4
Carthami flos12Glycyrrhizae radix4
Corydalis tuber12Lumbricus24
Forsythiae fructus12Citri unshius pericarpium12
Massa medicata fermentata12
Amomi fructus12
Cyperi rhizoma12
Ziniberis rhizoma6
Cinnamomi ramulus6
Scutellariae radix6
Liriopis seu ophiopogonis tuber6

Table 3 . Soft extract herbal medications for daily dosage.

Palmul-tang soft extract (May 8, 2023–May 25, 2023)Amount (g)Gumiganghwal-tang soft extract (May 25, 2023–June 30, 2023)Amount (g)
Poria sclerotium0.675Osteroici seu notopterygii radix et rhizoma1.9740
Ginseng radix1.260Saposhnikoviae radix2.0304
Atractylodis rhizoma1.485Cnidii rhizoma1.9350
Glycyrrhizae radix1.980Angelicae dahuricae radix1.1250
Rehmanniae radix preparata2.160Atractylodis rhizoma1.3950
Paeoniae radix alba1.485Scutellariae radix2.6550
Cnidii rhizoma1.935Rehmanniae radix1.0800
Angelica gigantis radix1.485Asiasari radix et rhizoma0.4914
Glycyrrhizae radix0.8316

Table 4 . Manual muscle test.

GradeCategoryFunction of the muscle
Grade 0Zero (Z)No visible or palpable muscle contraction.
Grade 1Trace (T)Feel contraction with palpation; no visible movement.
Grade 2−P−Less than full ROM in gravity eliminated plane.
Grade 2Poor (P)Full ROM in gravity eliminated plane with no resistance.
Grade 2+P+Full ROM in gravity eliminated plane, breaks upon minimum resistance.
Grade 3−F−Less than full ROM against gravity, but more than 50%.
Grade 3Fair (F)Full ROM against gravity, with no resistance.
Grade 3+F+Full ROM against gravity, breaks upon minimum resistance.
Grade 4Good (G)Full ROM against gravity with moderate resistance.
Grade 5Normal (N)Full ROM against gravity with maximum resistance.

ROM, range of motion..


Table 5 . Manual muscle test results.

MovementApril 22, 2023April 28, 2023May 4, 2023May 12, 2023May 19, 2023May 26, 2023June 2, 2023June 9, 2023June 16, 2023June 23, 2023June 30, 2023
Hip flexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Hip extensionN/F+N/F+N/F+N/F+N/NN/NN/NN/NN/NN/NN/N
Knee flexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Knee extensionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Ankle dorsiflexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N
Ankle plantarflexionN/F+N/F+N/F+N/GN/NN/NN/NN/NN/NN/NN/N

N, normal; F, fair; G, good..


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Feb 29, 2024 Vol.41 No.1, pp. 1~73

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