Fracture patterns at the Medieval Leper Hospital in Chichester

Fancy shoes and painful feet: Hallux valgus and fracture risk in medieval Cambridge, England

OBJECTIVE

Hallux valgus, the lateral deviation of the great toe, can result in poor balance, impaired mobility and is an independent risk factor for falls. This research aims to compare the prevalence of hallux valgus in subpopulations of medieval Cambridge, England, and to examine the relationship between hallux valgus and fractures to examine the impact of impaired mobility and poor balance caused by this condition.

MATERIALS

177 adult individuals from four cemeteries located in Cambridge, England.

METHODS

Human remains were macroscopically and radiographically assessed.

RESULTS

Hallux valgus was identified in 18 % of individuals and was significantly more common during the 14th-15th centuries than the 11th-13th centuries. The highest prevalence was observed in the friary (43 %), followed by the Hospital (23 %), the rurban parish cemetery (10 %), and the rural parish cemetery (3%). Fractures from falls were significantly more common in those with hallux valgus than those without.

CONCLUSION

The increased prevalence of hallux valgus identified in individuals from the 14th to 15th centuries coincided with the adoption of new footwear with pointed toes. Those that adopted this fashion trend appear to have been more likely to develop balance and mobility problems that resulted in an increased risk of falls.

SIGNIFICANCE

This is the first study to explore the relationship between foot problems and functional ability by studying hallux valgus in archaeological assemblages.

LIMITATIONS

Falls are complex and determining the mechanism of injury in human skeletal remains is not always possible.

FURTHER RESEARCH

Fracture prevalence rates may have been affected by biological factors and underlying pathological conditions.

Toward a bioarchaeology of urbanization: Demography, health, and behavior in cities in the past

Urbanization is one of the most important settlement shifts in human history and has been the focus of research within bioarchaeology for decades. However, there have been limited attempts to synthesize the results of these studies in order to gain a broader perspective on whether or how urbanization affects the biology, demography, and behavior of humans, and how these potential effects are embodied in the human skeleton. This paper outlines how bioarchaeology is well-suited to examine urbanization in the past, and we provide an overview and examples of three main ways in which urbanization is studied in bioarchaeological research: comparison of (often contemporaneous) urban and rural sites, synchronic studies of the variation that exists within and between urban sites, and investigations of changes that occur within urban sites over time. Studies of urbanization, both within bioarchaeology and in other fields of study, face a number of limitations, including a lack of a consensus regarding what urban and urbanization mean, the assumed dichotomous nature of urban versus rural settlements, the supposition that urbanization is universally bad for people, and the assumption (at least in practice) of homogeneity within urban and rural populations. Bioarchaeologists can address these limitations by utilizing a wide array of data and methods, and the studies described here collectively demonstrate the complex, nuanced, and highly variable effects of urbanization.

Medieval injuries: Skeletal trauma as an indicator of past living conditions and hazard risk in Cambridge, England

Objective

To explore how medieval living conditions, occupation, and an individual's role within society impacted their risk of skeletal trauma.

Materials

The skeletal remains of 314 individuals from medieval Cambridge that were buried in the parish cemetery of All Saints by the Castle (n = 84), the Augustinian friary (n = 75), and the cemetery of the Hospital of St John the Evangelist (n = 155) were analyzed.

Methods

Macroscopic examination and plain radiographs were used to classify fracture type. The causative mechanisms and forces applied to a bone were inferred based on fracture morphology.

Results

The skeletal trauma observed represents accidental injuries, likely sustained through occupational or everyday activities, and violence. The highest prevalence rate was observed on the individuals buried at All Saints by the Castle (44%, n = 37/84), and the lowest was seen at the Hospital of St John (27%, n = 42/155). Fractures were more prevalent in males (40%, n = 57/143) than females (26%, n = 25/95).

Conclusions

Skeletal trauma was highest in All Saints parish burial ground, indicating that the poor, whether working urban or rurally, had the highest risk of injury. The pattern and types of fractures observed suggests that males experienced more severe traumatic events than females. However, females that were routinely involved in manual labor were also at increased risk of injury.

Significance

This article enhances our understanding of how traumatic injuries differed by age, sex, and burial locations in the medieval period.

Further research

Additional comparative studies in different geographical regions are needed to determine how representative these findings are.

An accident at work? Traumatic lesions in the skeleton of a 4th millennium BCE "wagon driver" from Sharakhalsun, Russia

The study of ante-mortem trauma is a popular and important aspect of palaeopathological analysis. The majority of publications focus on a particular assemblage, skeletal element or type of fracture, with case studies of single individuals with multiple/unusual traumata being much rarer in the literature. This paper presents the case of an adult male from the Bronze Age site of Sharakhalsun, Russia, buried, uniquely, in a sitting position on a fully assembled wagon, who displayed evidence for multiple healed ante-mortem fractures of the cranium, axial and appendicular skeleton. The mechanisms and likely etiologies of the fractures are presented, with reference to modern and 19th century clinical literature, and possible interpretations suggested: that the individual was involved in a severe accident involving a wagon or draft animals, or both, a number of years before his death. The suggestion is also made that the unique burial position of the individual was a form of commemoration by the community of the survival and recovery of the individual from such a serious incident.

Skeletal fractures resulting from fatal falls: A review of the literature

To investigate what is currently known about skeletal blunt force trauma (BFT) resulting from falls, and how valuable that research is in contributing to forensic anthropology investigations and interpretations of circumstances of death, a comprehensive review of forensic anthropology, forensic pathology and clinical medicine literature was performed. Forensic anthropology literature identified that establishing the type of fall from the analysis of BFT is difficult given the uniqueness of each fall event, the complexities involved with identify BFT and, in particular, the limited available research documenting fracture patterning and morphologies. Comparatively, skeletal BFT resulting from fatal falls is well documented in the forensic pathology and clinical medicine literature. These disciplines cover a wide range of fall types (free falls, falls in juveniles, specific fractures produced from falls, falls down staircases, falls resulting in impalements, and 'other' fall types), provide details on how the nature of the fall influences the skeletal fracturing, and documents the anatomical regions susceptible to fracturing. Whilst these contributions may assist forensic anthropologists, they provide limited details of fracture patterns and morphologies and thus further research investigating the details of skeletal BFT resulting from fatal falls is required.

Long bone fractures identified in the Joseon Dynasty human skeletons of Korea

Fracture is one of the pathological signs most frequently encountered in archaeologically obtained bones. To expand the paleopathological knowledge on traumatic injuries, it is desirable to secure data on long bone fractures from as wide a geographic and temporal range as possible. We present, for the first time, evidence of long bone fractures in a 16th-18th century Joseon skeletal series (n=96). In this study, we found 3 Colles' fractures of the radius in 2 individual cases. The pattern of fractures was unique. Although previous reports show that the ulna is broken more often than the radius, ulnar fracture associated with fending off a blunt attack was rare in our series (1/7 cases). Transverse fractures, typically caused by intentional violence, were also very rare (1/7 cases) in this study. These results may reflect the relatively tranquil lives of the Joseon people in 16th-18th century Korea. We also found post-fracture complications such as deformations, bone length shortening, and osteomyelitis. The present study would be of interest to medical scientists in related fields because it is one of the few studies conducted on long bone fractures among pre-modern societies in East Asian countries, thus far.

Ancient skeletal evidence for leprosy in India (2000 B.C.)

Background

Leprosy is a chronic infectious disease caused by Mycobacterium leprae that affects almost 250,000 people worldwide. The timing of first infection, geographic origin, and pattern of transmission of the disease are still under investigation. Comparative genomics research has suggested M. leprae evolved either in East Africa or South Asia during the Late Pleistocene before spreading to Europe and the rest of the World. The earliest widely accepted evidence for leprosy is in Asian texts dated to 600 B.C.

Methodology/Principal Findings

We report an analysis of pathological conditions in skeletal remains from the second millennium B.C. in India. A middle aged adult male skeleton demonstrates pathological changes in the rhinomaxillary region, degenerative joint disease, infectious involvement of the tibia (periostitis), and injury to the peripheral skeleton. The presence and patterning of lesions was subject to a process of differential diagnosis for leprosy including treponemal disease, leishmaniasis, tuberculosis, osteomyelitis, and non-specific infection.

Conclusions/Significance

Results indicate that lepromatous leprosy was present in India by 2000 B.C. This evidence represents the oldest documented skeletal evidence for the disease. Our results indicate that Vedic burial traditions in cases of leprosy were present in northwest India prior to the first millennium B.C. Our results also support translations of early Vedic scriptures as the first textual reference to leprosy. The presence of leprosy in skeletal material dated to the post-urban phase of the Indus Age suggests that if M. leprae evolved in Africa, the disease migrated to India before the Late Holocene, possibly during the third millennium B.C. at a time when there was substantial interaction among the Indus Civilization, Mesopotamia, and Egypt. This evidence should be impetus to look for additional skeletal and molecular evidence of leprosy in India and Africa to confirm the African origin of the disease.

Statistical basis for positive identification in forensic anthropology

Forensic scientists are often expected to present the likelihood of DNA identifications in US courts based on comparative population data, yet forensic anthropologists tend not to quantify the strength of an osteological identification. Because forensic anthropologists are trained first and foremost as physical anthropologists, they emphasize estimation problems at the expense of evidentiary problems, but this approach must be reexamined. In this paper, the statistical bases for presenting osteological and dental evidence are outlined, using a forensic case as a motivating example. A brief overview of Bayesian statistics is provided, and methods to calculate likelihood ratios for five aspects of the biological profile are demonstrated. This paper emphasizes the definition of appropriate reference samples and of the "population at large," and points out the conceptual differences between them. Several databases are introduced for both reference information and to characterize the "population at large," and new data are compiled to calculate the frequency of specific characters, such as age or fractures, within the "population at large." Despite small individual likelihood ratios for age, sex, and stature in the case example, the power of this approach is that, assuming each likelihood ratio is independent, the product rule can be applied. In this particular example, it is over three million times more likely to obtain the observed osteological and dental data if the identification is correct than if the identification is incorrect. This likelihood ratio is a convincing statistic that can support the forensic anthropologist's opinion on personal identity in court.

Fractures in late medieval skeletal populations from Serbia

Bone fractures were analyzed from skeletal remains of 861 adult individuals from six cemeteries dating to the Late Medieval period in Serbia. Results of the study were compared to other cemetery populations (635 individual skeletons) of the same date and region in an attempt to understand fracture patterns. The association of types of fractures and their prevalence with sex, age at death, cemetery site, and information deriving from historical sources are discussed. Results showed that the long bone fracture frequency was 0.7%, and the majority of the fractures were the result of direct force. This rate is similar to some studies of contemporary British skeletal samples. However, it is much lower than for some other Old World sites. Cranial vault fractures had a rate of 6.7%, and of the facial skeleton, 1.3%; the frontal bone was the most affected of bones of the cranial vault. Injuries were more common on the upper extremities (0.8%) compared to the lower (0.6%). However, the fibula was the most fractured bone (2.8%), followed by the ulna (2.4%). This pattern is similar to three of six Late Medieval urban sites in Britain. These findings suggest that this rural community was exposed to a low risk of trauma, probably related mostly to accidents sustained during farming, and rarely to interpersonal violence.

Age-related cortical bone loss in women from a 3rd–4th century AD population from England

Age-dependent cortical bone loss in adult females from a skeletal assemblage from 3rd-4th century AD England was studied using metacarpal radiogrammetry. Results showed reduced peak cortical bone thickness compared with modern subjects, and the magnitude of cortical bone loss in older females compared with their younger counterparts was greater than that documented for a modern reference population. An elevated prevalence of fractures classically associated with osteoporosis was also observed in the over-50-year cohort. The severity of osteoporosis in this group is difficult to explain in terms of extraneous factors relating to 3rd-4th century lifestyles. Given the important genetic component in osteoporosis, the results may indicate some inherent susceptibility in this particular population to the disease, and ways in which this possibility might be further explored are suggested.

Interventions improve gait regularity in patients with peripheral neuropathy while walking on an irregular surface under low light

OBJECTIVES

To determine which, if any, of three inexpensive interventions improve gait regularity in patients with peripheral neuropathy (PN) while walking on an irregular surface under low-light conditions.

DESIGN

Observational.

SETTING

University of Michigan Biomechanics Research Laboratory.

PARTICIPANTS

Forty-two patients with PN (20 women), mean age+/-standard deviation=64.5+/-9.7.

INTERVENTIONS

A straight cane, touch of a vertical surface, or semirigid ankle orthoses.

MEASUREMENTS

Step-width variability and range, step-time variability, and speed.

RESULTS

Subjects demonstrated significantly less step-width variability (mean=41.0+/-1.5, 36.9+/-1.6, 37.2+/-1.3, and 35.9+/-1.5 mm for baseline, cane, orthoses, and vertical surface, respectively; P<.0001) and range (182.7+/-7.4, 163.7+/-8.3, 164.3+/-7.4, 154.3+/-6.9 mm for baseline, cane, orthoses and vertical surface, respectively; P=.0006) with each of the interventions than under baseline conditions. Step-time variability significantly decreased with use of the orthoses and vertical surface but not the cane (P=.0001). Use of a cane, but not orthoses or vertical surface, was associated with decreased speed (0.79+/-0.03, 0.73+/-0.03, 0.79+/-0.03, 0.80+/-0.03 m/s for baseline, cane, orthoses, and vertical surface, respectively; P=.0001).

CONCLUSION

Older patients with PN demonstrate improved spatial and temporal measures of gait regularity with the use of a cane, ankle orthoses, or touch of a vertical surface while walking under challenging conditions. The decreased speed and stigma associated with the cane and uncertain availability of a vertical surface suggest that the ankle orthoses may be the most practical intervention.

[Paleopathological skeleton findings. Macroscopical and radiographical studies of 364 individuals from a medieval graveyard]

Paleopathological examinations can give an idea of diseases and living conditions in ancient populations. An archaeological collection of 364 late medieval/early modern skeletons from the thirteenth to eighteenth centuries, excavated from a church cemetery in the Rostock town center, was examined palaeopathologically. The type and frequency of certain diseases within this north German urban population are described. The majority of the skeletons were from adults with a remarkably low percentage of children. Skeletal malformations (e.g. gap formations of the spinal column) were not abnormally represented. With the exception of single individuals, metabolic disorders or unusual infectious diseases could not be diagnosed. Degenerative diseases often found at the joints and the spinal column showed substantially lower prevalences in comparison with reference rural populations. Individual cases of benign and rare malignant neoplasms could be documented. Traumatic injuries as well as dental pathological changes were rare. In summary it can be concluded that the individuals buried here belonged to a better social class within the medieval population of Rostock.

Factors associated with falls in older patients with diffuse polyneuropathy

OBJECTIVES

To identify clinical factors associated with falls by older persons with polyneuropathy (PN).

DESIGN

A cross-sectional study of 82 subjects aged 50 to 85 with clinical and electrodiagnostic evidence of PN.

SETTING

Electrodiagnostic and biomechanical research laboratories.

PARTICIPANTS

Patients referred to the electrodiagnostic laboratory.

MEASUREMENTS

History and physical examination, including semiquantitative methods of peripheral nerve function, and clinical balance testing. Falls were defined by retrospective self-report over a 2-year period.

RESULTS

Forty (48.8%), 28 (34.1%), and 18 (22.0%) subjects reported a history of at least one fall, multiple falls, and injurious falls, respectively. Factors associated with single and multiple falls were similar, so only results for multiple and injurious falls are reported. Bivariate analysis showed that an increased body mass index (BMI) and more severe PN (as determined by the Michigan Diabetes Neuropathy Score) were associated with both fall categories. Men reporting falls also demonstrated a decreased unipedal stance time. Age, sex, nerve conduction study parameters, Romberg testing, medications, and comorbidities were not consistently associated with either fall category. Logistic regression demonstrated that multiple and injurious falls were associated with an increased BMI and more severe PN, controlling for age, sex, medications, and comorbidities (pseudo R2 = 0.458 and 0.484, respectively).

CONCLUSIONS

Although previous work has demonstrated that all older persons with PN are at increased risk for falls, patients with increased BMI and more severe PN are at particularly high risk and should be targeted for intervention.

Skeletal Manifestations of Leprosy: Analysis of 137 Patients from Different Clinical Settings in the Pre- and Postmodern Treatment Eras

This study was conducted to further characterize the nature of leprosy-related bone alterations, to develop a hypothesis of their pathophysiology, and to define the impact of treatment on bone damage. Radiographs of 60 patients under care at the Carville, Louisiana leprosy hospital were compared with 50 from the early (before availability of effective treatment) part of this century and with 27 from the Toronto (Ontario, Canada) leprosy clinic. Two-thirds of lesions were so severe that distal digital tufts had been lost to whittling, resorption, or fragmentation. Fifty percent were felt to be pathognomonic for the changes of leprosy. Resorption, fragmentation, and malaligned fractures are highly suggestive of leprosy, while diaphyseal whittling appears specific when medullary sclerosis or wavy diaphyseal borders are present. Medicinal intervention appeared to be of limited benefit for bone damage; perhaps greater attention to joint/bone protection (as recommended in diabetes management) will prove helpful. Environmental adjustment to minimize injury risk and daily limb examination for injury are recommended.