Lovell, 1997

Trauma Analysis in Paleopathology
NANCY C. LOVELL
Department of Anthropology, Universityof Alberta,
Edmonton, AB T6G 2H4, Canada
KEY WORDS fracture; di sl ocati on; vi ol ence; head i njury
ABSTRACT Thi s paper revi ews the mechani sms of i njury and the types of
fractures that most commonl y affect the human skel eton, presents descri pti ve
protocol s for crani al and postcrani al fractures adapted from cl i ni cal and
forensi c medi ci ne, and summari zes anatomi cal l y the i njuri es most l i kel y to be
found i n archaeol ogi cal skel etons al ong wi th thei r most common causes and
compl i cati ons. Mechani sms of i njury are categori zed as di rect and i ndi rect
trauma, stress, and fracture that occurs secondary to pathol ogy. These are
consi dered to be the proxi mate, or most di rect, causes of i njury and they are
i nuenced by i ntri nsi c bi ol ogi cal factors such as age and sex, and extri nsi c
envi ronmental factors, both physi cal and soci ocul tural , that may be thought
of as the ul ti mate, or remote, causes of i njury. I nterpersonal coni ct may be
one of those causes but the skel etal evi dence i tsel f i s rarel y concl usi ve and
must therefore be eval uated i n i ts i ndi vi dual , popul ati onal , soci ocul tural , and
physi cal context. A cauti onary tal e regardi ng parry fractures i s presented as
an i l l ustrati on. Yrbk Phys Anthropol 40:139170, 1997.

1997Wiley-Liss, I nc.
Trauma may be dened many ways but
conventi onal l y i s understood to refer to an
i njury to l i vi ng ti ssue that i s caused by a
force or mechani sm extri nsi c to the body.
The anatomi cal i mportance and soci ocul -
tural i mpl i cati ons of trauma i n anti qui ty
l ong have been recogni zed and the descri p-
ti on of trauma i n human skel etal remai ns
and the i denti cati on and compari son of
trauma patterns among anci ent popul ati ons
therefore have a l engthy hi story. As the
di sci pl i ne of pal aeopathol ogy has devel oped,
the objecti ves of traumati c i njury anal ysi s
have shi fted from a focus on the i denti ca-
ti on and descri pti on of the earl i est and the
most unusual pathol ogi cal speci mens to the
i nterpretati on of the soci al , cul tural , or envi -
ronmental causes of traumati c i njury; thei r
rel ati onshi p to bi ol ogi cal vari abl es, such as
sex and age, that may have soci al or cul tural
rel evance; and thei r temporal and spati al
vari ati on. Thus, i nterpretati ons of the cause
of trauma i n anti qui ty range from i nter- and
i ntragroup coni ct (e.g., Angel , 1974; Ham-
perl , 1967; Janssens, 1970; Jurmai n, 1991;
Li ston and Baker, 1996; Shermi s, 1984;
Stewart, 1974; Wal ker, 1989; Wood-Jones,
1910; Zi vanovi c, 1982; and others)toenvi ron-
mental l y or occupati onal l y faci l i tated mi s-
adventure and acci dent (e.g., Angel , 1974;
Burrel l et al ., 1986; Cybul ski , 1992; Grauer
and Roberts, 1996; Kel l ey and Angel , 1987;
Lovejoy and Hei pl e, 1981; Wel l s, 1964; and
others). Al though great advances have been
made i n pal eopathol ogi cal di agnosi s and
i nterpretati on i n recent years, i nconsi sten-
ci es i n descri pti ons and i nterpretati ons of
trauma i n the l i terature, parti cul arl y as
they affect our understandi ng of the nature
and extent of i nterpersonal vi ol ence i n anti q-
ui ty, have made i t di ffi cul t to compare the
resul ts of di fferent studi es and to accept
wi th condence some concl usi ons. The pur-
pose of thi s paper, therefore, i s to revi ew
types of fractures and the mechani sms of
i njury, cri ti que protocol s for fracture descri p-
ti on, and consi der the probl ems of i nterpret-
i ng the causes of i njury. Al though an i mpor-
tant source of data for the study of the
hi story of medi ci ne, a di scussi on of skel etal
YEARBOOK OF PHYSI CAL ANTHROPOLOGY 40:139170 (1997)
1997 WI LEY-LI SS, I NC.

i ndi cators of surgi cal practi ce and other
medi cal i nterventi on i s beyond the scope of
thi s paper.
Schol ars have categori zed traumati c i nju-
ri es i n a vari ety of ways (Tabl e 1), but
general l y refer to both acci dental and i nten-
ti onal trauma, the former usual l y i ncl udi ng
most fractures and di sl ocati ons and the l at-
ter usual l y i ncl udi ng exampl es of surgi cal
i nterventi on and weapon wounds. I t may be
more prudent, however, to rst sort i njuri es
accordi ng to thei r predomi nant characteri s-
ti c, ei ther fracture
1
(any break i n the conti -
nui ty of a bone) or dislocation (the di spl ace-
ment of one or more bones at a joi nt), rather
than to cl assi fy i njuri es i n a manner that
i mpl i es causati on or i ntent.
DISLOCATIONS
Traumati c i njuri es to joi nts may resul t i n
parti al or compl ete di sl ocati ons. A di sl oca-
ti on, or l uxati on, occurs when the arti cul ar
surfaces of a joi nt are total l y di spl aced from
one another. A subl uxati on resul ts when the
arti cul ar surfaces are parti al l y di spl aced
but do retai n some contact. Al though di sl oca-
ti ons and subl uxati ons may be congeni tal or
spontaneous i n ori gi n, they are most com-
monl y caused by trauma and i n such cases i t
i s not uncommon for the joi nt di spl acement
to be associ ated wi th a fracture. Si nce di s-
pl acement cannot occur wi thout damage to
the joi nt capsul e and l i gaments, compl i ca-
ti ons such as the ossi cati on of membrane,
l i gament, and tendon attachments to bone
may ensue. Persi stent i nstabi l i ty of the joi nt
al so may resul t, parti cul arl y i n the shoul der
and ankl e, al though thi s compl i cati on can-
not be easi l y i denti ed i n archaeol ogi cal
skel etal remai ns. Osteoarthri ti s i s one of the
more common, and recogni zabl e, compl i ca-
ti ons and resul ts from damage to the arti cu-
l ar carti l age i tsel f or from prol onged i ncon-
gruence of the joi nt surfaces.
For joi nt di spl acements to be recogni zabl e
i n dry bone the i njury must have occurred
some ti me before the death of an i ndi vi dual
and remai ned unreduced (i .e., not set) l ong
enough for bone modi cati ons to take pl ace.
Some di sl ocati ons, such as of the di gi ts,
usual l y can be rel ati vel y qui ckl y and easi l y
reduced (but see Drei er, 1992), whi l e others,
such as of the vertebrae, may cause i mmedi -
ate death. I n ei ther case no evi dence of the
i njury wi l l be observabl e i n archaeol ogi cal
skel etons.
Di sl ocati ons tend to be more frequent i n
young and mi ddl e-aged adul ts, si nce i n sub-
adul ts a si mi l ar force i nstead causes epi phy-
seal separati on and i n ol der adul ts causes
fracture of osteoporoti c bones. The gl enohu-
meral joi nt i s a common si te of di sl ocati on,
the shal l owness of the shoul der joi nt mak-
i ng i t parti cul arl y suscepti bl e to di spl ace-
ment. Traumati c di sl ocati on of the femoral
head from the acetabul um, i n contrast, re-
qui res consi derabl e force and thi s si te i s
1
I nfracture and i nfracti on are al ternati ve terms for frac-
ture, parti cul arl y undi spl aced fractures, accordi ng to medi cal
di cti onari es (e.g., Stedman, 1982). Al though rarel y used i n
pal eopathol ogy, these terms may be seen i n the l i terature wi th a
di fferent meani ng: i nfracti on, for exampl e, has been dened as
an i ncompl ete fracture. I n the i nterests of devel opi ng cl ear and
standard termi nol ogy, these al ternati ve terms are not used i n
thi s revi ew.
TABLE 1. Variation in thecategorization of traumaticinjuries bydifferent authors
Knowl es (1983) Merbs (1989a)
Ortner and
Putschar (1981) Stei nbock (1976)
Roberts and
Manchester (1995) Thi s study
Fractures Fractures Fractures Fractures Fractures
3
Fractures
4
Di sl ocati ons Di sl ocati ons Di sl ocati ons Di sl ocati ons Di sl ocati ons Di sl ocati ons
Trephi nati on and
amputati on
Surgery Trephi nati on Sharp I nstruments
2
Osteochondri ti s
di ssecans
Weapon wounds Weapon wounds Weapon wounds Growth arrest l i nes
Exostoses Scal pi ng Scal pi ng Crushi ng i njuri es
Schmorl s nodes Dental trauma
1
Deformati on
1
Osteochondri ti s
di ssecans
Pregnancy-rel ated
1
I ncl udes crani al deformati on, l i ng of teeth, and other modi cati ons performed for aestheti c purposes.
2
I ncl udes surgery and weapon wounds.
3
I ncl udes pi erci ng i njuri es caused by kni fe and sword cuts, scal pi ng, and projecti l e poi nts (i .e., surgery and weapon wounds).
4
I ncl udes pi erci ng i njuri es caused by kni fe and sword cuts, scal pi ng, and projecti l e poi nts (i .e., surgery and weapon wounds), and crush
fractures caused by foot bi ndi ng and by crani al bi ndi ng and atteni ng.
140
YEARBOOK OF PHYSI CAL ANTHROPOLOGY [Vol . 40, 1997
more commonl y associ ated wi th congeni tal
di sl ocati ons.
FRACTURES
A fracture consi sts of an i ncompl ete or
compl ete break i n the conti nui ty of a bone.
The most common types of fractures, such as
transverse, spi ral , obl i que, and crush frac-
tures, resul t from di rect or i ndi rect trauma.
Two addi ti onal types of fractures, those re-
sul ti ng from stress and those secondary to
pathol ogy, are l ess common and have di s-
ti nct eti ol ogi es. Fracture types and thei r
associ ated mechani sms of i njury are re-
vi ewed bel ow (and summari zed i n Tabl e 2),
fol l owed by di scussi ons of fracture heal i ng
and compl i cati ons.
2
Mechanisms of injury and types
of fractures
Di rect trauma. When a break occurs at
the poi nt of i mpact i t i s referred to as a
di rect trauma i njury (Mi l l er and Mi l l er, 1979)
and the resul ti ng fracture may be trans-
verse, penetrati ng, commi nuted, or crush
(Fi g. 1). A transverse fracture resul ts from
force appl i ed i n, and appears as, a l i ne
perpendi cul ar to the l ongi tudi nal axi s of the
bone. Cl i ni cal l y, thi s i njury often resul ts
from a hard ki ck to the shi n and i s often seen
among soccer pl ayers. Typi cal l y, transverse
fractures are caused by a rel ati vel y smal l
force del i vered to a smal l area.
Parti al or compl ete penetrati on of the
bone cortex by cutti ng, pi erci ng, dri l l i ng, or
scrapi ng, such as the exci si on of pi eces of
crani al vaul t bones i n the practi ce of trephi -
nati on, or the amputati on of a l i mb segment
i s cl assed as a di rect trauma i njury. Penetrat-
i ng fractures typi cal l y are caused by appl i ca-
ti on of a l arge force to a smal l area. I n
archaeol ogi cal contexts, penetrati on coul d
be caused by a projecti l e poi nt, the bl ade of
an axe or sword, or a musket bal l (Bl ai r,
1983; Butl er, 1971). Wounds from arrow or
spear poi nts often can be i denti ed wi th
certai nty onl y i f the poi nt remai ns embed-
ded i n the bone and heal i ng woul d not be
evi dent i f such wounds were l i nked to the
death of the i ndi vi dual . The human remai ns
i n many hi stori c cemeteri es show the trau-
mati c resul ts of coni cts wi th bul l ets and
other projecti l es (e.g., Gi l l , 1994; Larsen et
al ., 1996; Owsl ey et al ., 1991). Earl y cases of
penetrati ng projecti l e wounds can be ex-
pected to show subsequent i nfecti on and/or
pronounced deformi ty i n the absence of sta-
bi l i zati on or rest of the i njured part. Some
penetrati ng fractures may al so be commi -
nuted, whi ch occurs when the bone i s broken
i n more than two pi eces. I n cl i ni cal cases,
2
The i nformati on provi ded here has been compi l ed from a
vari ety of sources, i ncl udi ng Adams (1987), Apl ey and Sol omon
(1992), Gusti l o (1991), Harkess and Ramsey (1991), and Schul tz
(1990).
TABLE 2. Summaryof mechanisms of injuryand associated types of fractures
Mechani sm of I njury Type of fracture Comments
Di rect trauma Penetrati ng Parti al or compl ete penetrati on of bone cortex
Commi nuted Bone i s broken i n more than two pi eces; most common i n l ong
bone di aphyses
Transverse Force appl i ed i n a l i ne perpendi cul ar to l ong axi s of the bone
Crush Most common i n cancel l ous bone
Depressi on Crushi ng force on one si de of the bone
Compressi on Crushi ng force on both si des
Pressure Force appl i ed to growi ng bone
I ndi rect trauma Spi ral Rotati onal and l ongi tudi nal stress on l ong axi s; often confused
wi th obl i que fracture
Obl i que Rotati onal and angul ar stress on l ong axi s; often confused wi th
spi ral fracture
Torus/greensti ck Bendi ng of the bone due to l ongi tudi nal compressi on; common i n
chi l dren
I mpacted Bone ends are dri ven i nto each other
Burst Found i n the spi ne due to verti cal compressi on
Commi nuted Force spl i ts i n several di recti ons and forms a T or Y shape
Avul si on Fracture due to tensi on at l i gament or tendon attachment
Stress Due to repeti ti ve force, usual l y perpendi cul ar to l ong axi s
May be confused wi th di rect trauma transverse fracture
Secondary to pathol ogy Secondary to l ocal i zed or systemi c di sease that has weakened the
bone
141
TRAUMA ANALYSI S Lovel l ]
hi gh vel oci ty bul l ets and bl unt force trauma
to the crani um typi cal l y cause commi nuted
fractures.
Crush fractures most commonl y occur i n
cancel l ous bone and resul t from the appl i ca-
ti on of a di rect force to the bone, whi ch
col l apses on i tsel f. Three types of crush
fractures are recogni zed: depressi on, com-
pressi on, and pressure. The rst refers to
crushi ng on one si de of the bone (especi al l y
common on the ectocrani um) whi l e the sec-
ond refers to a crushi ng force that ori gi nates
on both si des of the bone. The i ncompl ete
penetrati on of a bone by a l ow vel oci ty
projecti l e may resul t i n a crush fracture,
such as depressed fractures caused by the
i mpact of musket bal l s (Li ston and Baker,
1996) or shotgun pel l ets (Swan and Swan,
1989). Bl unt trauma, such as that produced
by a bl udgeon, st, or hammer, or when an
object i s dropped on the hand or foot, resul ts
i n crush fractures. The thi rd type of crush-
i ng i njury resul ts when devel opi ng bone
responds to the appl i cati on of di rect force.
Exampl es of thi s l ast type are cul tural l y
mandated bone al terati ons, such as the shap-
i ng of i mmature crani al and foot bones by
vari ous types of bi ndi ng for beauti cati on.
Rarel y, di rect trauma i njury that brui ses
a joi nt may fracture arti cul ar carti l age, and
someti mes the subchondral bone as wel l ,
causi ng separati on of a fragment from the
margi n of the arti cul ar surface. Thi s resul t-
i ng l esi on may be confused wi th osteochon-
dri ti s di ssecans, whi ch i s caused by asepti c
necrosi s and i s usual l y seen as the compl ete
or i ncompl ete separati on of a porti on of joi nt
carti l age and subchondral bone, most com-
monl y on the femoral condyl es. Osteochon-
dri ti s di ssecans i s usual l y recogni zed i n dry
bone as a pi t, often 2 to 5 mm i n di ameter, i n
the subchondral bone, al though new bone
formati on may parti al l y or compl etel y l l
the defect or may produce a deposi t that
exceeds the l evel of the normal arti cul ar
surface. The eti ol ogy of osteochondri ti s di sse-
cans i s uncertai n but i ndi rect trauma i s
thought to pl ay at l east a contri butory rol e.
I ndi rect trauma. When a fracture occurs
i n a pl ace other than the poi nt of i mpact i t i s
sai d to resul t from i ndi rect trauma (Mi l l er
and Mi l l er, 1972). Obl i que, spi ral , green-
sti ck, i mpacted, burst, and avul si on frac-
tures are consequences of i ndi rect trauma
(Fi g. 2). An obl i que fracture, where the l i ne
angl es across the l ongi tudi nal axi s, i s i ndi ca-
ti ve of a combi ned angul ated/rotated force
(Harkess and Ramsey, 1991). I f the fracture
i s wel l heal ed, thi s break i s easi l y confused
Fi g. 1. Fractures caused by di rect trauma. From l eft to ri ght: transverse, penetrati ng, commi nuted,
and crush.
142
wi th a spi ral l i ne. A spi ral fracture l i ne
wi nds down around a l ong bone shaft due to
a rotati onal and downward l oadi ng stress on
the l ongi tudi nal axi s. I n some cases, such a
force appl i ed to the ti bi a resul ts i n a fracture-
di sl ocati on of the ankl e rather than a spi ral
fracture (Harkess and Ramsey, 1991); at
other ti mes, the force resul ts i n an associ -
ated proxi mal bul ar fracture.
Torus or greensti ck fractures resul t from
bendi ng or buckl i ng of bone when stress i s
appl i ed. These often are due to i ndi rect
trauma and are most commonl y seen i n
chi l dren, whose bones are sti l l pl i abl e and
hence l ess l i kel y to break, i nstead produci ng
a l ocal i zed bul gi ng on the bone. An exampl e
i s a greensti ck fracture of the cl avi cl e that
resul ts duri ng chi l dbi rth when the chi l ds
bi acromi al breadth i s too l arge to pass easi l y
through the mother s pel vi c outl et. Green-
sti ck fractures are al so characteri zed by an
i ncompl ete fracture i nvol vi ng onl y the con-
vex si de of a bone that has been subjected to
bendi ng stress. I n adul ts the ri bs are com-
monl y affected.
Less common fractures resul ti ng from i n-
di rect trauma are i mpacted, avul si on, and
burst fractures. An i mpacted fracture occurs
when the bone ends at a fracture si te are
dri ven i nto each other by the force of i njury.
Cl i ni cal l y, thi s i s often seen i n the proxi mal
humerus as the resul t of a fal l onto an
outstretched hand, and i n the metacarpal s
as a resul t of trauma to the st when
punchi ng. An avul si on fracture i s caused
when a joi nt capsul e, l i gament, or tendon i s
strai ned and pul l s away from i ts attachment
to the bone, teari ng a pi ece of bone wi th i t. A
parti cul ar type of avul si on fracture l eaves a
transverse fracture l i ne: a transverse frac-
ture may occur to the ul nar ol ecranon pro-
cess or the patel l a i f the extensor muscl es
contract forceful l y whi l e the joi nt i s exed,
and i n extreme cases the bone fragments
wi l l separate and may heal wi thout uni ti ng.
A burst fracture i s l ocated i n the spi ne. I t
resul ts from a verti cal compressi on that
ruptures the i ntervertebral di sc through the
vertebral end pl ate, forci ng di sc ti ssue i nto
the vertebral body (Fi g. 3). A mi l d form of
thi s i njury i s often seen i n archaeol ogi cal
speci mens as a smal l , l ocal i zed, typi cal l y
ci rcul ar, depressi on i n the end pl ate that i s
usual l y cal l ed a Schmorl s node.
Commi nuted fractures may be due to i ndi -
rect trauma as wel l as to di rect trauma. The
i ndi rect commi nuted fracture i s patterned
l i ke a T or Y, and i s produced by a force
that passes through the bone, spl i tti ng i t i n
several di recti ons (Perki ns, 1958). Crush
Fi g. 2. Fractures caused by i ndi rect trauma. From l eft to ri ght: obl i que, spi ral , greensti ck due to
angul ar force, greensti ck due to compressi on, i mpacti on, and avul si on.
143
fractures al so can be found as a resul t of
i ndi rect trauma, such as i n the cal caneus
after a person has jumped from a hei ght.
Stress fractures. Repeti ti ve force can re-
sul t i n a stress or fati gue fracture. The usual
areas of occurrence are the metatarsal , cal ca-
neus, and ti bi a (Wi l son and Katz, 1969).
Stress fractures i n the metatarsal s are some-
ti mes referred to as marchi ng fractures,
si nce they are often di agnosed i n mi l i tary
cadets. Those i n the ti bi a have been known
for some ti me to affect dancers, whi l e the
i ncreased i nterest i n joggi ng and aerobi c
danci ng i n recent decades as wel l as the
adopti on of al ternati ve rel i gi ous practi ces
has l ed to thei r hi gher preval ence i n other
segments of western soci ety (Burrows, 1956;
Cohen et al ., 1974). The fracture l i ne i s
usual l y perpendi cul ar to the l ongi tudi nal
axi s, therefore probl ems may ari se i n tryi ng
to di sti ngui sh between stress and di rect
trauma transverse i njuri es. Commonl y a
stress fracture wi l l be vi si bl e as a nondi s-
pl aced l i ne or crack i n the bone, cal l ed a
hai rl i ne fracture, whi ch i s not detectabl e
radi ol ogi cal l y unti l a bony cal l us has formed
over the break.
Fracturessecondarytopathol ogy. Frac-
tures often occur secondari l y to a di sease
al ready present i n the body. Systemi c di s-
eases such as metabol i c di sturbances and
nutri ti onal deci enci es l eave bone vul ner-
abl e to spontaneous fracture or to fracture
from mi nor trauma. For exampl e, postmeno-
pausal femal es may suffer fractures i f thei r
bones have been weakened by osteoporosi s.
Other skel etal markers of speci c di sease
may ai d i n attri buti ng cause to the fracture:
neopl asti c fractures are seen when the break
i s through or adjacent to a tumor that i s i n,
or of, bone, and the col l apse of vertebral
bodi es i s not an uncommon consequence of
tubercul osi s i n the spi ne (Potts di sease).
Fracture healing
Durati on of heal i ng. Fractures begi n to
heal i mmedi atel y after the bone i s broken,
but the process di ffers for cancel l ous and
tubul ar bone. Most i nvesti gators i denti fy
ve overl appi ng stages i n tubul ar bone heal -
i ng (Adams, 1987; Apl ey and Sol omon, 1992;
Paton, 1984). Tabl e 3 summari zes the acti vi -
ti es of these stages and the approxi mate
ti me after i njury that each i s observed.
Heal i ng normal l y i s not vi si bl e on radi o-
graphs unti l approxi matel y 2 to 3 weeks
after the i njury, when a cal l us of woven
bone, the resul t of cel l prol i ferati on from the
peri osteum, marrow cavi ty, and surround-
i ng connecti ve ti ssue, appears around the
si te of i njury. The cal l us i nternal l y and
external l y bri dges the gap caused by the
fracture and stabi l i zes the fractured ends.
Consol i dati on of thi s woven bone i nto ma-
ture l amel l ar bone occurs subsequentl y, but
the durati on of the process depends upon the
nature of the fracture and the type of bone
i nvol ved. I n a phal anx, a sol i dl y uni ted
fracture may devel op i n l ess than 1 month,
whi l e the same transformati on may take up
to 6 months i n a ti bi a or femur. Bones of the
Fi g. 3. Burst fractures of the l umbar vertebrae i n a
young adul t mal e from the hi stori c Fur Trade peri od i n
Al berta.
144
upper l i mb tend to heal faster than do those
of the l ower l i mbs, and spi ral and obl i que
fractures heal faster than do transverse
fractures.
I n contrast to compact tubul ar bone, can-
cel l ous bone has a meshl i ke structure wi th
no medul l ary canal . Thi s provi des a much
l arger area of contact between fracture frag-
ments, whi ch faci l i tates heal i ng. I n addi -
ti on, thi s mesh can be more easi l y pen-
etrated by bone-formi ng ti ssue than can
compact bone, so the uni on occurs di rectl y
between bone fragments i nstead of i ndi -
rectl y vi a the peri osteal and endosteal cal -
l us. The i ni ti al haematoma i s penetrated by
prol i ferati ng bone cel l s whi ch grow from
opposi ng fracture surfaces. The devel opi ng
ti ssues fuse when they meet and subse-
quentl y cal ci fy to form woven bone. Heal i ng
i s thus si mpl er and faster i n cancel l ous bone
than i n compact bone.
Because there i s a del ay before heal i ng i s
vi si bl e macroscopi cal l y or radi ographi cal l y,
i t may be di ffi cul t to di sti ngui sh some post-
mortem breaks from unheal ed premortem
fractures. Peri mortem fractures i s the term
gi ven to such i njuri es, whi ch may have
occurred i n the recent antemortem peri od
(i .e., up to 3 weeks before death) and are
therefore unheal ed, or that al ternati vel y
may have occurred i n a postmortem peri od
that i s of i ndetermi nate l ength (perhaps
weeks or months) but duri ng whi ch the bone
i s sti l l rel ati vel y fresh and i ts organi c compo-
nents not yet deteri orated. Otherwi se, di sti n-
gui shi ng between antemortem/peri mortem
trauma and that whi ch cl earl y occurred
after death i s predi cated upon the di fferent
fracture properti es associ ated wi th bone that
retai ns i ts vi scoel asti c nature and bone that
does not, and upon the di fferent appear-
ances of bone surfaces after vari ous postmor-
tem i nterval s (Bui kstra and Ubel aker, 1994;
Mapl es, 1986; Mann and Murphy, 1990;
Ubel aker and Adams, 1995). Antemortem or
peri mortem fractures can be i denti ed by 1)
any evi dence of heal i ng or i nammati on; 2)
the uni form presence of stai ns from water,
soi l , or vegetati on on broken and adjacent
bone surfaces; 3) the presence of greensti ck
fractures, i ncompl ete fractures, spi ral frac-
tures, and depressed or compressed frac-
tures; 4) obl i que angl es on fracture edges;
and/or 5) a pattern of concentri c ci rcul ar,
radi ati ng, or stel l ate fracture l i nes. Post-
mortem fractures, i n contrast, tend to be
characteri zed by 1) smal l er fragments; 2)
nonuni form col orati on of the fracture ends
and the adjacent bone surface, especi al l y
l i ght-col or ed edges; 3) squar ed fr actur e
edges; and 4) absence of fracture patterni ng
due to the i ncreased tendency of dry, bri ttl e,
bone to shatter on i mpact.
Compl i cati ons of heal i ng. Compl i ca-
ti ons shoul d be assessed when exami ni ng
fractures because they may provi de i nforma-
ti on regardi ng mobi l i ty, morbi di ty, mortal -
i ty, and medi cal tr eatment or the l ack
thereof. I n addi ti on to the fracture types
descri bed above, the rel ati onshi p of the frac-
ture to surroundi ng ti ssue i s referred to as
cl osed or open. When the fractured bone
does not come i nto contact wi th the outer
TABLE 3. Theprocess and duration of fracturehealingin tubular bones
(Adams, 1987, Apleyand Solomon, 1993, and Paton, 1984)
Heal i ng stage Heal i ng processes Durati on
Haematoma formati on Bl ood from torn vessel s seeps out and forms a haematoma 24 hours
Fractured bone ends di e due to l ack of bl ood suppl y
Cel l ul ar prol i ferati on Osteoi d i s deposi ted around each fragment by osteobl asts of
peri osteum and endosteum and pushes haematoma asi de
3 weeks
Fracture i s bri dged; vi si bl e i n dry bone
Cal l us formati on Cal l us of woven bone forms from mi neral i zati on of osteoi d and
acts as a spl i nt for peri osteal and endosteal surfaces
3 to 9 weeks
Vi si bl e radi ol ogi cal l y
Consol i dati on Mature l amel l ar bone forms from cal l us precursor and resul ts
i n a sol i dl y uni ted fracture area
Vari es by skel etal el e-
ment from a few weeks
to a few months
Remodel l i ng Gradual remodel l i ng of bone to i ts ori gi nal form, strength-
eni ng al ong l i nes of mechani cal stress
6 to 9 years
I ncreased densi ty on radi ographs marks the fracture si te on
adul t bones
145
surface of the ski n, the fracture i s termed
cl osed. An open fracture, al so known as a
compound fracture, i s when the bone pro-
trudes through the ski n or the ski n i s broken
to the l evel of the bone, as i n a crushi ng or
penetrati ng wound. Open fractures are prone
to i nfecti on, whi ch hi nders the uni on of the
fracture and creates i nstabi l i ty. A pathogen,
Staphylococcus aureus i n about 90%of cl i ni -
cal cases (Ortner and Putschar, 1981), may
be i ntroduced to the body through an open
fracture from surface contami nati on or from
a penetrati ng i nstrument or contami nant.
Al though there i s a tendency to regard l ocal -
i zed i nfecti ons as rel ated to observed frac-
tures, but to i nterpret nonl ocal i zed i nfec-
ti ons as unrel ated to fracture, posttraumati c
i nfecti on may i n fact be present ei ther as a
l ocal i zed condi ti on or, due to hematogenous
di ssemi nati on of the pathogen, as a systemi c
i nfecti on. Whether l ocal i zed or systemi c, i f
the bodys i mmune system i s unabl e to com-
bat the i nfecti on successful l y bony response
i s usual l y vi si bl e i n the form of peri osti ti s
(an i nammati on of the peri osteum)or osteo-
myel i ti s (a more severe bone i nfecti on that
i nvol ves the medul l ary cavi ty). Peri osti ti s i s
usual l y characteri zed by focal peri osteal bone
deposi ti on that may eventual l y for m a
pl aquel i ke sheet over the cortex. Osteomyel i -
ti s i s i denti ed by a thi ckened contour i n the
area of the fracture and the bone may feel
heavi er. Pathognomoni c evi dence of osteomy-
el i ti s resul ts from the devel opment of sub-
peri osteal abscesses that depri ve the bone of
i ts bl ood suppl y and l ead to necrosi s (the
dead bone forms a sequestrum). The peri os-
teum conti nues to produce new, hypervascu-
l ar bone around the sequestrum, formi ng a
shel l of bone cal l ed i nvol ucrum. The subperi -
osteal pus must escape through the i nvol u-
crum to the ski n surface, however, and i n
doi ng so forms one or more si nuses (cl oacae)
i n the i nvol ucrum for pus drai nage. I n dry
bone the sequestrum, l yi ng under the i nvol u-
crum, may be vi si bl e through a cl oacal open-
i ng. Posttraumati c osteomyel i ti s i s most com-
monl y observed i n the crani um and l ong
bones of archaeol ogi cal skel etons.
Fractures i nevi tabl y resul t i n the rupture
of mi nor bl ood vessel s but thi s i s not usual l y
a seri ous compl i cati on. I n some cases, how-
ever, bone di spl acement can compress or
twi st bl ood vessel s and l ead to i schemi a.
Thi s wi l l del ay the heal i ng process and coul d
l ead to bone death i f unrel i eved. Avascul ar
necrosi s normal l y occurs near the arti cul ar
ends of bones where the bl ood suppl y to
subchondral bone i s l i mi ted. Death of the
ti ssue begi ns a week after the nutri ent
suppl y i s reduced and may conti nue for up to
4 years. Duri ng thi s ti me the bone l oses i ts
trabecul ar structure, becomes granul ar, and
begi ns to di si ntegrate due to muscl e stress
or body wei ght. The adjacent arti cul ar carti -
l age al so di es as a resul t of deci ent nouri sh-
ment, usual l y resul ti ng i n osteoarthri ti s.
Nerve i njuri es al so may be associ ated
wi th fractures. Three types of nerve i njuri es
are general l y recogni zed. Damage i s sl i ght
i n neurapraxi a and resul ts i n temporary
i mpai rment that corrects i tsel f wi thi n a few
weeks. I n contrast, the i nternal nerve archi -
tecture i s preserved but axons are badl y
damaged i n axonotmesi s, resul ti ng i n peri ph-
er al degener ati on that may take many
months to heal . Such a l esi on may resul t
from pi nchi ng, crushi ng, or prol onged pres-
sure. The most seri ous type of nerve i njury,
neurotmesi s, i nvol ves compl ete di vi si on of a
nerve, ei ther through severi ng or severe
scarri ng, and requi res surgi cal repai r. The
consequences of these types of nerve i njuri es
range from l oss of sensati on to l oss of func-
ti on. Usual l y the l oss i s temporary, but
muscl e atrophy may resul t and i f the nerve
l oss i s prol onged or permanent the bones
wi l l di spl ay si gns of di suse atrophy as wel l .
Thi s sequel woul d be most l i kel y i n archaeo-
l ogi cal cases of neurotmesi s. I n addi ti on, i f
there i s l oss of i nnervati on to the fracture
si te, the i ndi vi dual wi l l not feel pai n and
may therefore conti nue to use the broken
bone, i mpai ri ng heal i ng. Fracture of the
vertebral col umn may resul t i n damage to
the spi nal cord or spi nal nerves, wi th paral y-
si s bel ow the l evel of the i njury a possi bl e
outcome. Depressed skul l fractures wi th en-
docrani al di spl acement are usual l y associ -
ated wi th si gni cant brai n i njury, whi ch
must al so be consi dered i n cases of l i near
fractures of the crani al vaul t.
Another compl i cati on i s posttraumati c os-
si cati on of a haematoma, whi ch resul ts
when absorpti on of the haematoma i s pre-
vented by excessi ve stress pl aced on the
146
peri osteum. A smooth mass of bone i s macro-
scopi cal l y vi si bl e after 2 months, wi th cal ci -
cati on bei ng vi si bl e radi ol ogi cal l y a few
weeks after the i njury. Al though usual l y
beni gn, movement may be restri cted i f there
i s joi nt i nvol vement.
I f joi nt functi on i s affected by traumati c
i njury, osteoarthri ti s may devel op as a com-
pl i cati on. Sti ffness caused by brous adhe-
si ons or joi nt swel l i ng may l ead to prol onged
di suse of the joi nt or l i mb. Shorteni ng or
angul ati on may resul t i n some l oss of nor-
mal functi on i n the affected l i mb or i n the
joi nts di rectl y above and bel ow the fracture;
thi s may be di ffi cul t to i nterpret si nce un-
usual bi omechani cal stress at a joi nt i n
whi ch a fractured bone parti ci pates may
cause osteoarthri ti s, but i t i s al so possi bl e
for a joi nt on an uni njured l i mb to be af-
fected. The l atter mi ght occur, for exampl e,
i f wei ght beari ng was shi fted i n order to
favor the i njured l eg. Premature deteri ora-
ti on of arti cul ar carti l age and subsequent
deteri orati on of subchondral bone are com-
mon compl i cati ons of breaks affecti ng the
joi nt surface i tsel f, si nce carti l age repai r i s a
very sl ow process. Such fractures al so can
resul t i n ankyl osi s of the joi nt.
Three nal compl i cati ons of fractures are
del ayed uni on, nonuni on, and mal uni on. I n
cl i ni cal setti ngs the uni on of a fracture i s
dened as del ayed i f i t has not occurred i n
the ti me expected for that skel etal el ement,
age, and sex of the i ndi vi dual , and i t may
eventual l y be cl assed as a nonuni on. I n dry
bone speci mens, of course, del ayed but even-
tual l y successful uni on cannot be di sti n-
gui shed from undel ayed uni on. Several fac-
tors may i mpede the process of heal i ng, but
overal l poor heal th and/or nutri ti on i n an-
ci ent popul ati ons may be a l argel y unrecog-
ni zed contr i butor (Gr auer and Rober ts,
1996).
The di agnosi s of nonuni on i s appl i ed when
the fracture fragments fai l to uni te and the
marrow cavi ty seal s. Radi ol ogi cal l y, non-
uni on may be i denti ed by scl erosi s at the
bone ends. After a prol onged peri od of ti me,
the fragments take on a rounded appear-
ance at thei r ends, whi ch are connected by
brous ti ssue. Nonuni on may resul t from
i nadequate bone heal i ng due to i nfecti on,
i nadequate bl ood suppl y, i nsuffi ci ency of vi -
tami n D or C or of cal ci um, excessi ve move-
ment between bone fragments duri ng heal -
i ng, soft ti ssue bei ng caught between the
fragment ends, i nadequate contact between
the fragments, presence of forei gn materi al ,
or from the destructi on of bone due to pathol -
ogy or the i njury i tsel f (Al tner et al ., 1975;
Karl strom and Ol erud, 1974; Sevi tt, 1981;
Stewart, 1974; Uri st et al ., 1954; Yami gashi
and Yoshi mura, 1955). I f there i s persi stent
movement between the ununi ted ends, a
pseudarthrosi s, or fal se joi nt, may form,
al though thi s compl i cati on i s rel ati vel y rare
(Stewart, 1974). Studi es of modern human
popul ati ons i ndi cate a frequency of pseudar-
throsi s of l ess than 5% (Heppenstal l , 1980;
Uri st et al ., 1954), whi l e an exami nati on of
data from temporal l y, geographi cal l y, and
cul tural di verse archaeol ogi cal popul ati ons
reveal s an average frequency of 2% (Burrel l
et al ., 1986; Ji menez, 1994; Lovejoy et al .,
1981; Stewart, 1974). Among al l opri mates,
data from Brambl ett (1967), Jurmai n (1989),
Lovel l (1990), and Schul tz (1937, 1939) al so
gi ve an average pseudarthrosi s frequency of
approxi matel y 2%.
A mal uni on consi sts of a fracture that
heal s l eavi ng a deformi ty. Thi s may occur
when a fracture has not been reduced or
when reducti on was not mai ntai ned, l eavi ng
the fragments to heal grossl y angul ated or
excessi vel y shortened. Shorteni ng i s caused
by overl ap, substanti al angul ati on, crush-
i ng, or gross bone l oss. I njuri es to growi ng
bone that affect the epi physes and l ead to
premature fusi on of the growth pl ate may
resul t i n shorteni ng, as may bone i nfarcti on
resul ti ng from si ckl e cel l di sease, whi ch
most often affects the epi physes of the grow-
i ng skel eton, especi al l y those of the proxi -
mal femur. The presence of a shortened bone
i s most detri mental to the l ower, wei ght-
beari ng l i mbs, al though a di fference of up to
20 mm i s consi dered by cl i ni cal practi ti oners
to be tol erabl e. A greater l oss i n l ength can
l ead to backache from pel vi s ti l ti ng and
l ateral and rotati onal spi nal devi ati on. Re-
cent studi es have i nterpreted mi ni mal defor-
mi ty i n bones that are l i kel y to be severel y
affected when fractured as evi dence for i m-
mobi l i zati on of the i njured part and possi bl e
medi cal treatment (Grauer and Roberts,
1996).
147
DESCRIPTIVE PROTOCOLS FOR
FRACTURES
Proper descri pti on of an i njury i s the rst
step i n trauma anal ysi s (Ortner and Putschar,
1981; Stei nbock, 1976) and i s the basi s for
determi ni ng the mechani sm, or proxi mate
cause, of the i njury. I n turn, an understand-
i ng of the proxi mate cause i s cruci al for the
i denti cati on of the ul ti mate cause of
trauma, usual l y behavi or. Proper descri p-
ti on of observed l esi ons al so provi des other
schol ars wi th an opportuni ty to agree or
di sagree wi th the di agnosi s and/or i nfer-
ences that are made about the soci ocul tural
or envi ronmental context of the i njury. Al -
though several model s proposed recentl y
have made great stri des i n standardi zi ng
descr i pti ve pr otocol s (e.g., Bui kstr a and
Ubel aker, 1994; Dastugue and Gervai s, 1992;
Grauer and Roberts, 1996; Roberts, 1991),
pal eopathol ogi sts have not yet reached a
consensus on descr i pti ve standar ds for
trauma and many are not al ways fami l i ar
wi th the underl yi ng mechani sms of i njury.
I deal l y, any method of fracture descri pti on
wi l l recogni ze two mai n sources of confusi on
i n i nterpretati on: the vari ati on i n appear-
ance expressed by fractures caused by the
same mechani sm of i njury, as wel l as the
si mi l ari ti es i n appearance di spl ayed by frac-
tures caused by di fferent mechani sms of
i njury. Ul ti matel y, proper fracture descri p-
ti on shoul d seek to i mprove the accuracy
and rel i abi l i ty of i nterpretati on wi thout ex-
ceedi ng the l i mi ts of i nference that are set
by the descri pti ve data themsel ves.
Al though fracture types are here sub-
sumed under thei r proxi mate cause, when
descri bi ng and i nterpreti ng i njury the frac-
ture type i s usual l y recogni zed rst. I denti -
cati on of the mechani sm of i njury then fol -
l ows l ogi cal l y, and the thi rd step i n trauma
anal ysi s i nvol ves i nterpretati on of the ul ti -
mate cause of the i njury. For exampl e, an
i mpacted fracture of the di stal radi us wi th
posteri or di spl acement of the di stal frag-
ment may be recogni zed as a Col l es fracture
due to i ts characteri sti c l ocati on and defor-
mi ty. The proxi mate cause of the i njury may
then be i denti ed as i ndi rect trauma. I nter-
preti ng the ul ti mate cause may be di ffi cul t,
but a fal l onto the outstretched hand woul d
be a l ogi cal concl usi on. I f the fracture was
observed i n an ol der femal e, the possi bi l i ty
of the fracture occurri ng secondary to osteo-
porosi s coul d al so be consi dered.
The pri nci pal ai m of most protocol s has
been to establ i sh standardi zed descri pti ons
for fractures observed i n dry bone, al though
addi ti onal objecti ves, such as the eval uati on
of evi dence for treatment of traumati c i nju-
ri es are someti mes al so stated (e.g., Grauer
and Roberts, 1996; Roberts, 1991). Three
recentl y devel oped protocol s are outl i ned
here.
The repatri ati on of Nati ve Ameri can pre-
hi stori c and hi stori c skel etal remai ns drove
the devel opment of standards for data col l ec-
ti on that i ncl udes procedures for document-
i ng fractures (Bui kstra and Ubel aker, 1994).
These procedures recogni ze ni ne types of
fractures and ei ght vari eti es of shape charac-
teri sti cs. Al l types and vari eti es are not
mutual l y excl usi ve, but may have restri cted
appl i cati on. Shape characteri sti cs, for ex-
ampl e, descri be l esi ons caused by bl unt or
sharp force and by projecti l es, as wel l as
radi ati ng fractures and amputati ons. Peri -
mortem fractures are i denti ed at a thi rd
l evel of descri pti on, fol l owed by sequel ae
such as heal i ng status and vari ous compl i ca-
ti ons. Di sl ocati ons are cl assed separatel y.
The recommended data col l ecti on forms and
descri pti ve protocol do not provi de for mal -
uni on as a component of fracture descri pti on
speci cal l y, but rather under the pathol ogy
category of abnormal i ty of shape, i n whi ch
mal uni on woul d be i denti ed as ei ther barel y
di scernabl e or cl earl y di scernabl e angul ati on.
Asecond method was desi gned speci cal l y
to descri be fractures i n a way that woul d
provi de the i nformati on necessary to exam-
i ne the technol ogy and knowl edge of treat-
ments i n past soci eti es (Grauer and Roberts,
1996; Roberts, 1991). The method descri bes
the l ocati on and type of fracture and empha-
si zes eval uati on of the success of l ong bone
heal i ng. Macr oscopi c and r adi ogr aphi c
means are empl oyed to assess compl i cati ons
of shorteni ng and deformi ty, and sequel ae
such as i nfecti on and osteoarthri ti s. Skul l
fractures are descri bed as resul ti ng from
bl unt or sharp force and are eval uated i n
terms of heal i ng as wel l as evi dence for
tr epanati on. The need for r adi ogr aphi c
148
eval uati on of fractures i n order to determi ne
the amount of heal i ng and the parti cul ars of
deformi ty and/or di spl acement i s stressed,
as i s the i mportance of radi ography for
detecti ng and i nterpreti ng wel l -remodel l ed
fractures (Grauer and Roberts, 1996; Rob-
er ts, 1991). Unfor tunatel y, r adi ogr aphi c
equi pment i s not al ways avai l abl e, espe-
ci al l y i n el d setti ngs, and the i nterpreta-
ti on of radi ographs may be made di ffi cul t by
postmortem al terati ons common i n archaeo-
l ogi cal contexts, such as soi l i ncl usi ons that
affect densi ty or the di fferenti al i denti ca-
ti on of osteoporosi s versus di ageneti c bone
l oss (Roberts, 1991).
Fi nal l y, a thi rd system concerns crani al
vaul t i njuri es, categori zi ng them as pi erc-
i ngs, depressi ons, gashes, cuts, and sl i ces
(Fi l er, 1992). The rst category i s descri bed
as consi stent wi th a penetrati ng i njury, the
second wi th bl unt force trauma, and the l ast
three as resul ti ng from edged/bl aded i mpl e-
ments, i ncl udi ng sharp projecti l es. The ma-
jori ty of these l esi ons were i nterpreted as
resul ti ng from i nterpersonal vi ol ence, an
assessment not i nconsi stent wi th the appar-
ent cul ture-hi stori cal context of the remai ns.
I t i s l i kel y that no one system of fracture
descri pti on wi l l sui t al l i nvesti gators, si nce
some wi l l be more or l ess concerned wi th the
affected body part, speci c compl i cati ons, or
possi bl e causati ve behavi ors. Most proto-
col s, however, share si mi l ar basi c categori es
of descri pti on. The method for fracture de-
scri pti on that i s presented bel ow i ncorpo-
rates these categori es i n a system adapted
from cl i ni cal and forensi c medi ci ne. I t i s
predi cated on i denti cati on of the skel etal
el ement(s) i nvol ved and the type of i njury, as
wel l as detai l ed descri pti ons of deformati on
and of any associ ated nontraumati c l esi ons
that may i ndi cate causal i ty or posti njury
compl i cati ons. The i nfor mati on thus ob-
tai ned then serves as a basi s for i nferences
about the mechani sm of i njury, whi ch can i n
turn provi de cl ues as to the soci al , cul tural ,
or envi ronmental associ ati ons of the i njury.
The method outl i nes descri pti ve features for
crani al and l ong bone fractures si nce these
predomi nate i n the pal eopathol ogi cal l i tera-
ture.
Description of cranial fractures
The i nterpretati on of the mechani sm of
i njury of crani al fractures rel i es on a vari ety
of characteri sti cs of the fracture, such as the
bones i nvol ved, patterni ng of fracture l i nes,
and pr esence of defor mati on (Gur dji an,
1975; Gusti l o, 1991; Hooper, 1969; for a
comprehensi ve di scussi on of l esi ons of the
cal vari um, see Kaufman et al ., 1997). Stress
fractures and fractures secondary to pathol -
ogy are uncommon i n the crani um. The most
common fractures of the crani um affect the
vaul t and are caused by di rect trauma.
These can be descri bed accordi ng to thei r
basi c type, usual l y l i near, crush, or penetrat-
i ng (Fi g. 4), whi ch are not necessari l y mutu-
al l y excl usi ve. Al though vaul t fractures are
most common, the base, maxi l l ae, nasal
bones, orbi ts, and/or zygomae may be frac-
tured al ternati vel y or addi ti onal l y, and the
temporomandi bul ar joi nt may be traumati -
cal l y di sl ocated.
Low vel oci ty, bl unt trauma to the head
may resul t i n si mpl e l i near fractures or
depressed (crush) fractures. The ki neti cs
i nvol ved may rel ate to accel erati on i njuri es,
Fi g. 4. Common fractures of the crani al vaul t. From l eft to ri ght: si mpl e l i near fracture due to bl unt
trauma, commi nuted depressed fracture due to bl unt trauma, and commi nuted penetrati ng fracture from
a hi gh vel oci ty projecti l e.
149
i n whi ch the head i s struck by an object and
set i n moti on, or decel erati on i njuri es, i n
whi ch the movi ng head suddenl y comes to a
hal t. I n ei ther case, the curve of the skul l at
the poi nt of i mpact tends to atten out, and
as a resul t the force of the i mpact i s di stri b-
uted over a rel ati vel y l arge area. The bone
surroundi ng the area of i mpact bends out-
ward, and, i f the deformi ty of the crani um i s
great enough, fracture l i nes begi n, usual l y
i n the areas subjected to bendi ng outward.
The areas of bendi ng are not uni forml y
ci rcul ar, si nce the degree and di recti on to
whi ch the fracture l i nes extend depends
upon both the magni tude of the appl i ed force
and the l ocal bony archi tecture.
Penetrati ng i njuri es of the crani um are
characteri zed by a smal l area of i mpact wi th
a l ocal i zed area of di storti on and are usual l y
caused by sharp-edged objects or projecti l es.
Wi th hi gher vel oci ty i mpact, the i nbendi ng
of the skul l remai ns l ocal i zed but the depth
of penetrati on i ncreased. As a general rul e,
when the ar ea of i mpact decr eases the
stresses are more l ocal i zed but greater i n
magni tude and the stresses i n surroundi ng
areas di mi ni sh. The severi ty of i mpact i n
di rect crani al trauma i s usual l y determi ned
from the extent and separati on of l i near
fractures, by the extent of commi nuti on of a
l ocal i zed fracture, or by the di spl acement of
bone fragments i n penetrati ng wounds.
I ndi rect trauma i njuri es are rel ati vel y
rare, but may resul t from verti cal l oadi ng
forces transmi tted from the feet or buttocks
when a person fal l s from a hei ght. A basi l ar
ri ngfracture around the foramen magnum
i s an exampl e of such an i njury; i t reects
i mpact forces transmi tted up through the
cervi cal spi ne and occi pi tal condyl es. Basi l ar
fractures through the petrous bones and
fractures of the mandi bul ar condyl es have
been observed to resul t from i mpact to the
chi n (Harvey and Jones, 1980).
Description of long bone fractures
I n contrast to fractures of at and i rregu-
l ar bones, fractures of appendi cul ar l ong
bones (and, by extensi on, short bones) often
r equi r e mor e compr ehensi ve descr i pti on
si nce thei r posi ti ons i n the skel eton and
thei r functi ons make them more suscepti bl e
to a vari ety of forces. Long bone fractures
fr om ar chaeol ogi cal contexts can be de-
scri bed i n a manner adapted from that used
i n cl i ni cal orthopedi cs (e.g., Gusti l o, 1991;
Harkess and Ramsey, 1991; Schul tz, 1990)
and can be rst cl assi ed as i ntraarti cul ar
(i nvol vi ng a joi nt, i ncl udi ng the metaphys-
eal regi on) or extraarti cul ar. I ntraarti cul ar
fractures are descri bed as ei ther l i near, com-
mi nuted, or i mpacted. Extraarti cul ar frac-
tures are descri bed as l i near, commi nuted,
or segmental .
Li near fractures fal l i nto three subtypes,
transverse, obl i que, and spi ral , al l of whi ch
have been previ ousl y descri bed. Commi -
nuted fractures are categori zed accordi ng to
the si ze of the fragments (mul ti pl e or butter-
y) and the percentage of the shaft (50%
or 50%) that i s i nvol ved. A buttery frac-
ture i s formed from a combi nati on of com-
pressi on and tensi on stresses that resul t i n
the separati on of a tri angul ar fragment of
bone. Segmental fractures are i denti ed by
the mul ti pl e fracture l i nes that di vi de the
bone i nto at l east two segments al ong a
l ongi tudi nal axi s. The l ocati on of the frac-
ture shoul d be noted as occurri ng at the
proxi mal end, di stal end, or shaft (ei ther the
proxi mal , mi ddl e, or di stal thi rd of the shaft
or one of the juncti ons thereof).
The nal components of l ong bone frac-
ture descri pti on are l ength, apposi ti on (shi ft),
rotati on, and angul ati on (al i gnment), i denti -
ed by the acronym, LARA. Conventi on
decrees that when descri bi ng the four compo-
nents the di stal fragment i s measured i n
rel ati on to the proxi mal fragment. The pri n-
ci pal ai ms here are to descri be fractures so
that the mechani sm of i njury can be de-
duced, and to di sti ngui sh fractures wi th no
or sl i ght deformi ty from those wi th marked
deformi ty.
Length of the bone i s measured wi th an
osteometri c board and the maxi mum l ength
i s recorded (per Bass, 1987). Length i s re-
corded as normal , di stracted, or shortened,
and i s determi ned by compari ng the i njured
bone to i ts counterpart, i f possi bl e. Di strac-
ti on i s a l engtheni ng of the bone and i s
caused by the separati on of bone fragments,
often due to muscul ar forces. Bones them-
sel ves may di stract a fracture, however,
such as when an i ntact ul na pul l s apart the
fragment ends of a fractured radi us or when
150
a fractured ti bi a i s associ ated wi th an i ntact
bul a. Di stracti on al so may be caused when
ti ssue i s caught between fragment ends. I n
contrast, shorteni ng resul ts when muscul ar
forces pul l the fragments over each other.
Thi s typi cal l y occurs when broken bones
have not been set, often due to severe pai n or
muscl e spasm, or i f a fracture reducti on
fai l ed because of i nstabi l i ty.
Apposition i s the percentage of bony con-
tact between fragment ends i n fresh i njuri es
and i s measured on radi ographs. Apposi ti on
from an x-ray i s measured usi ng a rul er and
i s expressed as a percentage, the hori zontal
di spl acement bei ng a functi on of the surface
area of bone. Therefore, i f there i s no hori zon-
tal di spl acement between the fractured bone
ends when heal ed, that i s, the bone ends are
i n perfect al i gnment, the bone i s 100% ap-
posed. I n dry bone, however, shi fti ng of the
di stal fragment i n rel ati on to the proxi mal
end can be recorded i n the absence of radi o-
graphs. I f the bone i s vi ewed i n anatomi cal
posi ti on, a medi al or l ateral shi ft may be
seen; i f vi ewed i n a l ateral posi ti on, anteri or
or posteri or di spl acement may be observed.
The shi ft i n both the anteroposteri or (AP)
and l ateral pl anes shoul d be noted, as the
bone can be di spl aced i n both di recti ons.
Rotation occurs when the di stal fragment
has turned rel ati ve to the proxi mal frag-
ment. There i s no measurement, but the
di stal porti on i s recorded as bei ng i nternal l y
or external l y rotated. Thi s i s usual l y easi l y
i denti abl e i n dry bone, especi al l y i f the
affected bone can be compared to the contra-
l ateral el ement. I f rotati on i s observed, the
adjacent joi nt surfaces shoul d be exami ned
si nce rotati on may resul t i n osteoarthri ti s,
or i n ankyl osi s of a joi nt i f l i gaments were
torn i n the i njury.
Angulation at the fracture si te i s mea-
sured i n degrees wi th a goni ometer. Thi s
measurement i s easi l y obtai ned from a radi o-
graph but al so may be obtai ned from the
bone. One end of the goni ometer i s pl aced on
the mi dl i ne of the proxi mal fragments l ongi -
tudi nal axi s, the other end on the axi s of the
di stal fragment wi th the center of the goni -
ometer di rectl y over the fracture si te. The
number of degrees the di stal fragment has
di spl aced i n rel ati on to the mi dl i ne of the
proxi mal fragment i s the angul ati on. The
di recti on of movement must al so be noted.
I n the AP vi ew, the di stal porti on of the
di stal fragment wi l l move medi al l y (varus)
or l ateral l y (val gus). I n the l ateral vi ew,
anteri or angul ati on refers to the di stal por-
ti on of the di stal fragment movi ng anteri -
orl y so that the fracture si te appears posteri -
orl y bowed. Posteri or angul ati on refers to
the di stal porti on of the di stal fragment
movi ng posteri orl y; the fracture si te appears
anteri orl y bowed. Degree and di recti on of
angul ati on shoul d be measured i n the AP
and l ateral posi ti ons as both pl anes are
often affected.
Examples of long bone fractures
The val ue and appl i cati on of standardi zed
fracture descri pti ons i s i l l ustrated here wi th
the descri pti on of radi ographs from four
cl i ni cal cases at the Uni versi ty of Al berta
Hospi tal i n Edmonton. Wi th known mecha-
ni sms of i njury, treatment, and fol l ow-up,
these cases unambi guousl y i l l ustrate the
skel etal effects of trauma and thei r vari abi l -
i ty of expressi on. For each set of radi o-
graphs, fractures were noted for thei r type,
the bone(s) i nvol ved, area of i nvol vement,
degree of heal i ng, l ength, apposi ti on, rota-
ti on, and angul ati on. Apposi ti on data are
reported to 5%. The measurement of angu-
l ati on was found to be the most probl emati c
and consequentl y al l angul ati on data are
presented to 2.
3
The sex and age of each
pati ent were recorded al though other per-
sonal , i denti fyi ng i nformati on was not re-
veal ed. Al though the degree of deformi ty i s
someti mes used to assess the exi stence
and/or qual i ty of medi cal treatment i n the
past, these exampl es rei nforce the observa-
ti on that the associ ati on i s not al ways di rect
(Grauer and Roberts, 1996). Fracture i nju-
ri es often i mprove wi th ti me but conversel y
they may deteri orate and i ndi vi dual re-
sponses to fracture vary wi del y.
A di rect trauma transverse fracture re-
sul ted when a 20-year-ol d mal e was ki cked
i n the shi n whi l e pl ayi ng soccer. Fi gure 5a i s
a l ateral vi ew radi ograph taken i mmedi -
3
I n order to eval uate i nterobserver error al l cl i ni cal cases were
i ndependentl y scored by N. Lovel l and C. Pri ns. The error i n
measured l ength as 1 mm; i n apposi ti on 5%; and i n angul a-
ti on 2; al l adequate for di sti ngui shi ng between none, sl i ght,
and marked deformi ty.
151
atel y posti njury that shows a transverse,
mi dshaft ti bi al fracture wi th no bul ar i n-
vol vement. The bone was perfectl y al i gned
on both the i ni ti al x-rays and those taken
more than 5 months l ater (Fi g. 5b). The
degree of cal l us formati on may appear to
those who are i nexperi enced wi th cl i ni cal
cases to be excessi ve, gi ven the apparent
l ack of angul ar deformi ty, di spl acement, or
commi nuti on, but thi s exampl e i s fai rl y typi -
cal of such i njury. Not al l transverse frac-
tures heal as ni cel y, however, and nonuni on,
despi te good al i gnment, may often occur i n
the ti bi a and/or bul a due to thei r i nherent
i nstabi l i ty when suppor ti ng the bodys
wei ght i n l ocomoti on.
I n some cases fractured bones heal wel l i n
one di mensi on, onl y to deteri orate i n an-
other. I ni ti al radi ographs of a 24-year-ol d
mal e i njured i n a motor vehi cl e acci dent
showed a transverse fracture at the juncti on
of the mi d and di stal thi rds of the l eft ti bi a,
wi th two bul ar fractures, one at the same
l evel as i n the ti bi a and another at the
proxi mal end of the shaft. Both ti bi a and
bul a were i n perfect al i gnment when vi ewed
anteroposteri orl y i mmedi atel y after the i n-
jury, al though 3 of posteri or angul ati on of
the ti bi a was noted i n the l ateral vi ew.
Fi gures 6a and 6b were taken more than 4
months after the i njury and the fracture
l i nes are sti l l vi si bl e. I n the AP vi ew, the
ti bi a has now shi fted l ateral l y by about the
wi dth of the bone cortex, and shows 4 of
val gus angul ati on. The mi dshaft bul ar frac-
ture al so di spl ays 4 of val gus i n the AP
pl ane. The l ateral vi ew, however, now shows
the ti bi a i n good al i gnment. Al though the
effects of hi gh vel oci ty vehi cul ar acci dents
may appear to have l i ttl e rel evance to ar-
chaeol ogi cal remai ns, mul ti pl e fractures of
thi s type have been noted i n hi stori c cases of
i njury i n horse-drawn cart and carri age
acci dents, and thi s case has obvi ous rel -
evance for modern forensi c i nvesti gati ons of
dry bone l esi ons.
Fi g. 5. Transverse fracture due to di rect trauma. a: Radi ograph taken i mmedi atel y posti njury,
showi ng a transverse mi dshaft fracture wi thout bul ar i nvol vement. b: Radi ograph taken more than 5
months l ater, showi ng cal l us around the fracture si te.
152
Fi gure 7a i s an i mmedi ate posti njury x-
ray of a 54-year-ol d mal e who fel l and suf-
fered obl i que, mi dshaft fractures of the ri ght
ti bi a and bul a. I n the AP vi ew there i s 11
of val gus angul ati on i n the ti bi a and 13 of
val gus angul ati on i n the bul a. The l ateral
vi ew shows 10 mm of shorteni ng i n both the
ti bi a and bul a and 1 of posteri or angul a-
ti on i n the ti bi a. Both bones have shi fted
anteri orl y about the wi dth of the bone cor-
tex. Fi gures 7b and 7c were taken 6 months
l ater. The fracture l i nes are sti l l very evi -
dent, l i ttl e cal l us i s seen, and the fragment
ends are rounded, suggesti ng nonuni on i n
both bones. Shorteni ng has l essened to 6
mm i n both the ti bi a and bul a. On the AP
vi ew the ti bi a retai ns 11 of val gus angul a-
ti on but the bul a now di spl ays onl y 4 of
val gus. I n the l ateral vi ew, posteri or angul a-
ti on i n the ti bi a has i ncreased to 4, 1 of
posteri or angul ati on i s seen i n the bul a,
and both bones retai n thei r anteri or shi fti ng.
A good exampl e of a rotati on i njury wi th
no bul ar i nvol vement i s a spi ral fracture of
the di stal thi rd of the ri ght ti bi a i n a 12-year-
ol d mal e who fel l off hi s bi cycl e (Fi g. 8).
Cal l us i s evi dent si nce the radi ographs were
taken about 2 months posti njury, and on the
APvi ew there i s 5 of val gus angul ati on. The
ti bi a i s not shortened, probabl y because the
i ntact bul a hel ped i t mai ntai n normal
l ength. On the l ateral vi ew, there i s 6 of
anteri or angul ati on i n the ti bi a.
ANATOMICAL SUMMARY OF
FRACTURES AND DISLOCATIONS
COMMONLY SEEN IN
ARCHAEOLOGICAL BONE
To ai d the di agnosi s of trauma accordi ng
to the mechani sm of i njury, thi s secti on i s
organi zed as an atl as and descri bes those
fractures and di sl ocati ons commonl y seen i n
archaeol ogi cal bone accordi ng to thei r ana-
tomi cal l ocati on. The possi bl e compl i cati ons
of the i njury and thei r affects on heal i ng al so
are descri bed.
Cranium
Fractures of the bones of the crani um vary
consi derabl y, but perhaps the most com-
monl y descri bed are those i nvol vi ng the at
bones of the vaul t. Typi cal l y, the patterni ng
of fracture l i nes on the crani um i s correl ated
wi th the severi ty of the force: whether a
Fi g. 6. Si ngl e ti bi al fracture wi th doubl e bul ar fracture. These radi ographs were taken more than 4
months posti njury and the fracture l i nes are sti l l vi si bl e. a:Anteri or vi ew. b:Lateral vi ew.
153
bl ow l ands on the frontal , occi pi tal , or pari -
etal regi on, a si ngl e l i near fracture l i ne
i ndi cates l ess force than does a pattern of
concentri c and radi ati ng stel l ate fracture
l i nes (Gurdji an et al ., 1950). The posi ti on of
fracture l i nes can someti mes be used to
i denti fy the poi nt of i mpact. Stel l ate, or
star-shaped, fracture l i nes form at the poi nt
of i mpact, for exampl e, and radi ati ng frac-
ture l i nes run l ateral l y, away from the poi nt
of i mpact. Concentri c heavi ng fractures are
caused by sheari ng forces and have charac-
teri sti cs, such as bevel angl e, that can di sti n-
gui sh between hi gh vel oci ty and bl unt
Fi g. 7. Obl i que, mi dshaft fractures of the ri ght ti bi a
and bul a. a:I mmedi atel y posti njury. Anteri or vi ew (b)
and l ateral vi ew (c) 6 months posti njury. Nonuni on i s
evi dent i n both bones.
154
trauma i njury (Berryman and Haun, 1996).
Wi th bl unt trauma the concentri c fractures
are caused by force from outsi de the cra-
ni um, whi ch l eads to bevel i ng on the i nner
tabl e, whereas wi th hi gh vel oci ty projecti l e
trauma the fractures are caused by pressure
from wi thi n the crani um, whi ch produces
bevel i ng on the outer tabl e. I denti cati on of
the poi nt of i mpact and the di recti on of the
force becomes i ncreasi ngl y di ffi cul t wi th
more severe trauma but the sequence of
mul ti pl e i mpacts usual l y can be determi ned
si nce a subsequentl y produced fracture wi l l
not cross a preexi sti ng one.
Di rect trauma i njuri es to the crani um
often occur when the head i s struck by a
movi ng object. Trauma from hi gh vel oci ty
objects, such as bul l ets and motori zed ve-
hi cl es, i s seen commonl y i n cl i ni cal cases,
but that from l ower vel oci ty objects (e.g.,
bri cks, rocks, bl udgeons, push carts, wag-
ons) i s al so observed today and undoubtedl y
occurred i n the past. Di rect trauma to the
crani um al so occurs i f the head stri kes the
ground after a fal l or jump from a hei ght or
when bal ance i s l ost after l andi ng on the
feet. These l ow vel oci ty i mpacts usual l y
resul t i n l i near fractures. Li near fracture
l i nes tend to sweep around the thi ck, bony
buttresses of the crani um (i .e., the petrous
bones, mastoi d process, etc.) unl ess they
approach these areas perpendi cul arl y. Si nce
the structural l y weak areas of the crani um
are most prone to devel op fracture l i nes, the
unfused crani al sutures i n chi l dren wi l l
readi l y separate to accommodate the forces
of i mpact. Al ternati vel y, i n very young chi l -
dren the crani al bones may bend i nward
wi thout fracturi ng and the depressed defor-
mi ty may persi st.
Cl i ni cal l y, bl unt trauma i njuri es to the
crani um usual l y cause l i near fractures of
the vaul t and the appearance of these frac-
ture l i nes may hel p i denti fy the poi nt of
i mpact and the mechani sm of i njury. Bl unt
trauma to the frontal bone, for exampl e,
produces fracture l i nes that radi ate through
the frontal si nus, the cri bri form pl ate, and
the orbi tal roofs, al though transverse frac-
ture l i nes affecti ng the temporal regi ons
may al so appear. Anteri or temporal i mpact
l eads to fracture l i nes that radi ate down,
across ei ther the orbi tal pl ate or the sphe-
noi d-temporal regi on. I n contrast, l ateral or
posteri or temporal i mpact produces fracture
l i nes that radi ate downwards ei ther i n front
of or behi nd the petrous porti on of the
temporal bone and extend across the crani al
base. I mpact to the occi pi tal bone usual l y
produces fracture l i nes that radi ate down to
the foramen magnum or the jugul ar fora-
men, and that may extend anteri orl y across
the crani al base. Trauma to the crani al base
must be severe i n order to cause a fracture,
si nce the bone here i s heavi l y buttressed. A
base fracture i s therefore consi dered to rep-
resent a severe i njury.
After vaul t fractures, sphenoi d fractures
are the most common cl i ni cal resul t of bl unt
trauma to the crani um (Unger et al ., 1990).
Unfortunatel y, sphenoi dal structures are
very fragi l e and thus prone to postmortem
damage as wel l as to fatal consequences of
fracture and therefore i t may be di ffi cul t to
i denti fy sphenoi d fractures i n archaeol ogi -
cal skel etons. Faci al fractures, ei ther due to
di rect or i ndi rect trauma, are often very
compl ex but commonl y heal adequatel y wi th-
Fi g. 8. Spi ral fracture, 2 months posti njury. Anteri or
vi ew i s on the l eft and l ateral vi ew i s on the ri ght.
155
out medi cal treatment. Si nce the zygoma,
maxi l l a, and orbi tal margi n are mutual l y
supporti ve, a fracture of one of these bones
usual l y i nvol ves a fracture of at l east one of
the others. Fractures of the nasal bones,
whi l e usual l y not severe, are not uncommon.
These are often cal l ed depressed fractures
(e.g., Fi l er, 1992) al though thi s descri pti on
refers to the observed deformi ty of the nasal
bri dge, not the type of i njury. Cl i ni cal l y,
i nterpersonal vi ol ence often produces smal l
fractures of the nasal and zygomati c bones.
Crush fractures of the crani al vaul t are
commonl y seen i n archaeol ogi cal human
remai ns and are caused by l ow vel oci ty
di rect trauma (Fi g. 9). Lesser force i s i ndi -
cated by the l ack of di spl acement of bone
fragments, whi l e greater force i s character-
i zed by i nward di spl acement. A porti on of
bone mi ght be compl etel y detached i f great
force i s appl i ed, parti cul arl y i f the object has
a smal l stri ki ng surface, but more often seen
i n archaeol ogi cal remai ns i s the i ncompl ete
detachment of the bone (Fi g. 10). The frac-
ture l i ne on the ectocrani um i s usual l y i r-
regul ar and may be commi nuted, produci ng
a cobweb or mosai c pattern. The depressed
area i ndi cates the poi nt of i mpact, from
whi ch l i near fractures radi ate. Cl i ni cal l y,
bl ows from hammers, repl ace pokers, and
the butt ends of axes are commonl y respon-
si bl e for i ncompl etel y detached depressi on
fractures, as are fal l s onto the sharp edge of
furni ture or concrete steps (Pol son et al .,
1985).
Penetrati ng i njuri es of the crani um are
caused by poi nted and edged objects (e.g.,
kni ves, swords) or by bul l ets. Heavy cutti ng-
edged weapons that are used i n a choppi ng
manner wi l l produce crush i njuri es i n addi -
ti on to penetrati on, and further i njury may
be caused i f the embedded weapon i s re-
moved wi th a twi sti ng moti on. Thi s damage
i s often i ndi cated by spl i nteri ng of the bone
wi th outward di spl acement near the i ni ti al
i mpact si te. The type and si ze of wound
produced by a projecti l e depends upon the
si ze of the projecti l e, the speed at whi ch i t
stri kes the bone, and the di stance i t travel s.
Hi stori cal skel etons may exhi bi t evi dence of
gunshot trauma, al though these i njuri es
woul d be l ess severe i n terms of bone frag-
mentati on and destructi on than those typi -
cal l y found i n a metropol i tan trauma center
today. Earl y musket bal l s, for exampl e, had
l ow vel oci ty characteri sti cs due to thei r
spheri cal shape and the poor qual i ty of gun
powder (Butl er, 1971). Hi gh vel oci ty bul l ets
(3,000 ft/sec) were not devel oped unti l
al most 1900, a date that usual l y pl aces
Fi g. 9. Wel l -heal ed, crush fracture of the ri ght pari eto-temporal regi on.
156
human remai ns i n a forensi c rather than
archaeol ogi cal context. Detai l s of the i nter-
pretati on of modern gunshot wounds can be
found i n many textbooks on forensi c medi -
ci ne.
Possi bl e compl i cati ons of crani al fractures
i ncl ude di spl acement of bone fragments (mal -
uni on), i ndi rect trauma i njuri es el sewhere
on the crani um due to the transmi ssi on of
i mpact force, and soft ti ssue damage. The
l ocati on of the i mpact determi nes the subse-
quent consequences of the i njury due to the
di fferent anatomi cal structures i n the cra-
ni um. Li near fractures usual l y i nvol ve both
the i nner and outer tabl es of the crani um
but do not i nvol ve di spl acement or depres-
si on of the bone and thus are often not
consi dered as seri ous as those i njuri es resul t-
i ng from greater force. Compl i cati ons can
ari se, however, due to transmi ssi on of the
force of i mpact, such as when di rect trauma
to the back of the crani um produces i ndi rect
effects on the orbi tal pl ates. The conse-
quences of crani al fractures can be fatal i f
the bl ood vessel s runni ng al ong the i nner
tabl es of the crani um (e.g., mi ddl e meni n-
geal arteri es) are torn, al though thi s compl i -
cati on i s unl i kel y to be detected wi th cer-
tai nty i n archaeol ogi cal remai ns.
Mandible
The mandi bl e forms what i s essenti al l y
part of a ri ng structure, and therefore a
fracture on one si de i s commonl y accompa-
ni ed by a bal anci ng fracture on the other
si de. Usual l y the fracture affects the hori zon-
tal ramus or angl e on one si de and the
condyl e on the opposi te si de. Fractures at
the angl e very often communi cate wi th the
Fi g. 10. Depressi on fracture of the crani al vaul t, showi ng radi ati ng and concentri c fracture l i nes.
Probabl y due to l ow vel oci ty bl unt trauma.
157
roots of the di stal mol ars. Very few mandi bu-
l ar fractures i n anci ent skul l s have been
descri bed but fractures of the ascendi ng
ramus, mandi bul ar angl e, and condyl ar pro-
cesses have been reported (Al exandersen,
1967). Asymmetri cal tooth wear and osteoar-
thri ti s at the temporomandi bul ar joi nt are
possi bl e compl i cati ons of jaw fractures.
Hyoid
Al though the hyoi d bone i s not al ways
recovered duri ng archaeol ogi cal excavati ons,
a peri mortem hyoi d fracture i s consi dered
strongl y suggesti ve of i nterpersonal vi o-
l ence through strangul ati on (Mapl es, 1986).
Vertebrae
The most common fractures of the verte-
brae are due to i ndi rect trauma, preexi sti ng
di sease, or stress. A very di sti ncti ve verte-
bral fracture i s the traumati c separati on of
the neural arch from the vertebral body at
the pars interarticularis (known as spondy-
l ol ysi s; Fi g. 11), whi ch appears to be a
common consequence of habi tual physi cal
stress (Ji menez, 1994; Merbs, 1989a, 1989b,
1995, 1996). Al though the spondyl ol ysi s seen
most often i n cl i ni cal setti ngs i s compl ete
separati on, comprehensi ve surveys of ar-
chaeol ogi cal skel etons i ndi cate that the con-
di ti on begi ns as i ncompl ete stress fractures
i n adol escents that may heal or, conversel y,
may progress to compl ete l ysi s by young
adul thood (Merbs, 1995). The condi ti on may
be i ni ti ated by an acute overl oad event that
causes mi crofractures, but i t i s general l y
agreed that the determi ni ng factor i s chroni c
trauma, wi th repeated stressi ng promoti ng
nonuni on of the mi crofractures. These fa-
ti gue fractures appear to have the greatest
popul ati onal frequency (approachi ng 50%)
among arcti c-adapted peopl es fol l owi ng tra-
di ti onal l i feways, but cl i ni cal l y they are
most often observed among athl etes and
l aborers whose acti vi ti es i nvol ve frequent
and l arge stress reversal s between l umbar
hyperextensi on and l umbar exi on (Merbs,
1989b, 1996). Reported sex di fferences i n the
preval ence of the condi ti on may be acti vi ty-
rel ated (Merbs, 1989b). Spondyl ol ysi s may
be uni l ateral or bi l ateral i n expressi on, but
predomi nates i n the l umbosacral regi on,
parti cul arl y L5 and, to a l esser degree, L4
(Merbs, 1996). Compl ete separati on i s fre-
quentl y accompani ed by anteri or sl i ppage of
the vertebral body (spondyl ol i sthesi s), but
functi onal compl i cati ons of thi s are rare
(Merbs, 1989b). A fracture wi th possi bl y a
si mi l ar ori gi n i s the traumati c separati on of
the ti p of the spi nous process of the seventh
cervi cal or rst thoraci c vertebra. Referred
to as cl ay-shovel l er s fracture (Roberts and
Manchester, 1995), i t may resul t from the
strenuous muscl e acti on associ ated wi th
shovel l i ng cl ay, cement, or rocks.
More common i n archaeol ogi cal vertebrae
than stress fractures are i ndi rect trauma
i njuri es, such as Schmorl s nodes. These
resul t from bul gi ng of the di scs nucl eus
pul posus, whi ch puts pressure on the verte-
bral end pl ate and l eads to bone resorpti on
i n the affected area. Herni ati on of the di sc
tends to occur gradual l y i n adul ts because
the nucl eus has l ost resi l i ency, whereas i t
may occur suddenl y i n younger i ndi vi dual s
Fi g. 11. Lumbar spondyl ol ysi s. Thi s separati on of
the neural arch and the body at the parsinterarticularis
i s usual l y attri buted to a fati gue fracture.
158
i n whom the nucl eus sti l l qui te gel ati nous
(Bul l ough and Boachi e-Adjei , 1988). I ndi -
rect vertebral damage al so can occur i n a fal l
or jump onto the feet, si nce the force of
i mpact i s carri ed up from the l ower l i mbs
through the spi ne.
Fractures secondary to pathol ogy are al so
common i n the vertebral col umn. The best
known cl i ni cal exampl e i s that of bi concave
vertebrae, whi ch resul t when i ntervertebral
di sks expand i nto the superi or or i nferi or
surfaces of vertebral bodi es that have been
weakened by osteoporosi s.
4
Si mi l arl y, com-
pressi on atteni ng of vertebral end pl ates
due to sparse, coarse trabecul ati on i n the
vertebral body i s a cl assi c feature of si ckl e
cel l di sease. Due to the greater strength of
the ri ms of the vertebral end pl ates, they
may be spared even when the vertebral body
i s compressed.
Al though di rect trauma i njuri es to the
vertebrae are rare, hai rl i ne transverse frac-
tures on, or posteri or to, the superi or arti cu-
l ar processes of the second cervi cal vertebra
are worth noti ng si nce they can resul t from
strangul ati on (Mapl es, 1986).
Ribs and sternum
Ri bs are known to i ncur stress fractures,
usual l y as a resul t of occupati onal or si mi -
l arl y habi tual l abor but someti mes as a
consequence of persi stent coughi ng or vomi t-
i ng. Most often, however, ri b fractures resul t
from di rect trauma, such as a bl ow or a fal l
agai nst a hard object (Adams, 1987). Cl i ni -
cal l y, ri b fractures are the most common
type of thoraci c i njury and are observed i n
60 to 70%of i ndi vi dual s admi tted to hospi tal
wi th bl unt chest tr auma (Car r er o and
Wayne, 1989). The di recti on of the i mpact
usual l y can be determi ned from the l ocati on
of the fracture, i .e., ri bs are usual l y frac-
tured near the angl e i f the force i s appl i ed
from the front; besi de the spi ne i f the force i s
appl i ed from the back; and besi de both the
spi ne and the sternum i f the force i s appl i ed
from the si des.
The fth to ni nth ri bs are most often
fractured (Fi g. 12). Fracture of the rst to
thi rd ri bs and/or the sternum i ndi cates that
the mechani sm of i njury was a hi gh ki neti c
force. Due to the exi bi l i ty of the ri b cage,
parti cul arl y i n the anteroposteri or di men-
si on, the degree of i nward di spl acement at
i mpact may have been much greater than
that di scernabl e posti njury, and thus soft
ti ssue damage may have been more severe
than mi ght be i nferred from the damage to
the bones themsel ves. Such soft ti ssue dam-
age i ncl udes l acerati on of the pl eura, l ungs,
or i ntercostal vessel s, whi ch woul d have
been l argel y untreatabl e i n earl i er ti mes
and thus may poi nt to a possi bl e cause of
death. Pneumothorax (the presence of ai r i n
the pl eural cavi ty) and hemothorax (the
presence of bl ood i n the pl eural cavi ty) may
be caused by ri b fractures at any l evel i n the
thoraci c cage and may be si mi l arl y l i fe-
threateni ng. Another seri ous compl i cati on
of ri b fracture occurs when there are at l east
two breaks i n one ri b. Thi s produces a
free-oati ng fragment and thus a ri sk of
4
A bi concave vertebra shoul d not be confused wi th a buttery
vertebra, whi ch i s a congeni tal mal formati on.
Fi g. 12. Mul ti pl e heal ed fractures of the l eft ri bs.
The l ocati on of the fractures, near the angl e, suggests
that the force was appl i ed from the front.
159
i nternal damage, referred to as ai l i njury.
Unfortunatel y, i f the soft ti ssue damage
caused by ri b fractures i s seri ous enough to
cause death, the bony i njuri es observed i n
the archaeol ogi cal skel eton woul d be i denti -
abl e onl y as peri mortem fractures. Heal ed
ri b fractures i n the archaeol ogi cal record
thus probabl y represent non-l i fe-threaten-
i ng trauma.
Clavicle
Cl avi cul ar fractures are most often caused
by a fal l onto the shoul der but occasi onal l y
resul t from a fal l onto an outstretched hand.
The break tends to occur at the juncti on of
the mi ddl e and l ateral thi rds, wi th down-
ward and medi al di spl acement of the l ateral
fr agment bei ng a common compl i cati on.
Si nce cl i ni cal treatment of cl avi cul ar frac-
tures i s usual l y l i mi ted to the use of a sl i ng
for 1 or 2 weeks for pai n rel i ef, heal ed
fractures often exhi bi t some deformi ty. Mal -
al i gned cl avi cul ar fractures i n archaeol ogi -
cal skel etons therefore do not necessari l y
poi nt to an absence of medi cal treatment.
Scapula
Scapul ar fractures are uncommon but are
usual l y the resul t of di rect trauma. Both the
at and i rregul ar porti ons of the scapul a
may be i nvol ved. Four types are commonl y
descri bed i n the cl i ni cal l i terature: 1) frac-
ture of the scapul ar body, whi ch may be
commi nuted but rarel y di spl aced because of
the l arge muscl es hol di ng the bone i n pl ace;
2) fracture of the neck, whi ch may l ead to
downward di spl acement of the gl enoi d; 3)
and 4) fractures of the acromi on and cora-
coi d processes, respecti vel y, whi ch range
from si mpl e cracks to commi nuti on and
whi ch may be associ ated wi th downward
di spl acement. Al though none of these i nju-
ri es i s usual l y consi dered seri ous, a possi bl e
compl i cati on of scapul ar fracture, especi al l y
i f the i njury occurs on the l eft si de, i s
pneumothorax (Carrero and Wayne, 1989).
Humerus
The most common humeral fractures i n
adul ts affect the neck, greater tuberosi ty,
and shaft. Neck fractures are most common
i n ol der women i n whom osteoporosi s has
weakened the bone. I ndi rect trauma from a
fal l onto an outstretched hand i s the usual
cause and i n more than 50% of these cases
the fracture i s sel f-stabi l i zed through i mpac-
ti on. Di rect trauma, i n the form of a fal l onto
the shoul der or a bl ow, may cause fracture of
the greater tuberosi ty. Shaft fractures are
most common i n the mi ddl e thi rd of the bone
and may be due to di rect or i ndi rect trauma.
The proxi mal hal f of the shaft i s a common
si te of fracture secondary to pathol ogy, such
as when the bone has been i nvaded by
metastati c di sease. Compl i cati ons of hu-
meral shaft fractures i ncl ude di spl acement,
nonuni on, and i njury to the radi al nerve.
I n contrast to the pattern observed i n
adul ts and descri bed above, humeral frac-
tures i n chi l dren tend to occur at the di stal
end, affecti ng the supracondyl ar, epi condy-
l ar, and condyl ar regi ons. Supracondyl ar
fractures are i ndi rect trauma i njuri es caused
by a fal l onto an outstretched arm, wi th
di spl acement occurri ng posteri orl y. Compl i -
cati ons i ncl ude mal uni on, damage to the
brachi al artery, and teari ng of the joi nt
capsul e wi th hemorrhage i nto the joi nt and
surroundi ng ti ssues. Epi condyl ar fractures
are usual l y medi al and may resul t from
di rect trauma but more often from avul si on
by exor muscl es i n a fal l . I f the avul sed
fragment enters the joi nt, whi ch occurs fre-
quentl y i n chi l dren, compl i cati ons i n terms
of reduced functi on and osteoarthri ti s usu-
al l y ensue. Thi s i njury may al so cause dam-
age to the ul nar nerve. Condyl ar fractures
are uncommon but al so tend to resul t from a
fal l . I n contrast to the medi al i nvol vement i n
epi condyl ar fractures, the l ateral porti on, or
capi tul um, i s usual l y i nvol ved i n condyl ar
fractures. Di spl acement i s not uncommon
and thi s i njury i s often compl i cated by defor-
mi ty, nonuni on, and osteoarthri ti s.
Ulna
Ul nar fractures are not especi al l y com-
mon cl i ni cal l y, but when they occur they
usual l y affect the ol ecranon or the shaft.
Ol ecranon fractures are more common i n
adul ts and resul t from the di rect trauma of a
fal l onto the poi nt of the el bow. Severi ty
ranges from a si mpl e crack to commi nuti on
and the i njury may be compl i cated by non-
uni on and osteoarthri ti s. Di aphyseal frac-
tures can resul t from ei ther di rect or i ndi -
160
rect trauma (Fi g. 13). They are prone to
severe di spl acement, mal uni on, nonuni on,
and to i nfecti on because of the bones proxi m-
i ty to the surface of the ski n. Fracture of the
proxi mal shaft of the ul na i s often associ ated
wi th the di sl ocati on of the radi al head. Thi s
i njury i s referred to as a Monteggi a fracture-
di sl ocati on. I t i s usual l y caused by a fal l onto
an outstretched hand wi th forced pronati on,
but i t may al so be caused by a bl ow to the
back of the upper forearm (i .e., a parry
fracture). Deformi ty commonl y character-
i zes thi s i njury i n archaeol ogi cal skel etons
si nce the fracture cannot be properl y re-
duced wi thout surgery.
Radius
Another forearm i njury, the Gal eazzi frac-
ture-di sl ocati on of the radi us, i s more com-
mon cl i ni cal l y than i s the Monteggi a frac-
ture-di sl ocati on. I t i s al so usual l y caused by
a fal l onto the hand, and si mi l arl y i t i s
di ffi cul t to real i gn wi thout surgi cal i nterven-
ti on. The fracture occurs near the juncti on of
the mi ddl e and di stal thi rds of the radi al
shaft and i s accompani ed by di sl ocati on of
the i nferi or radi o-ul nar joi nt. The most com-
mon radi us fracture occurs at the di stal
shaft and i s cal l ed the Col l esfracture. Cl i ni -
cal l y, i t i s the most common of al l fractures
i n adul ts over the age of 40, especi al l y
femal es, and i s nearl y al ways caused by the
i ndi rect trauma of a fal l onto the hand. The
break usual l y occurs about 2 cm above the
di stal arti cul ar surface of the radi us, and
the di stal fragment i s posteri orl y di spl aced
and usual l y i mpacted. Thi s i njury may be
associ ated wi th fracture of the styl oi d pro-
cess of the ul na. Al though fractures of the
di stal radi us, such as thi s, are one hundred-
fol d more frequent than are fractures of the
proxi mal radi us (Knowel den et al ., 1964),
fracture of the radi al head al so can resul t
from a fal l on an outstretched hand. Ob-
served mai nl y i n young adul ts, i t usual l y
appears as a crack wi thout di spl acement.
Commi nuti on i s possi bl e, however, and i n
such cases the i njury may be compl i cated by
osteoarthri ti s. I n contrast to these i ndi rect
trauma i njuri es, a si mpl e fracture of the
radi al shaft, somewhat l ess common than
the fracture-di sl ocati on i njuri es, usual l y re-
sul ts from di rect trauma.
Mal uni on i s the most common compl i ca-
ti on of radi us fractures, and absence of
medi cal treatment cannot be presumed i f
deformi ty i s observed si nce redi spl acement
i s very common cl i ni cal l y wi thi n a week of
fracture reducti on. I n archaeol ogi cal speci -
mens, at l east one study has reported that
radi us fractures rarel y heal ed wi thout defor-
mi ty (Grauer and Roberts, 1996).
Pelvis
I sol ated fractures of the pel vi c bones most
commonl y appear on the superi or and/or
i nferi or i schi o-pubi c ramus and the wi ng of
the i l i um. These fractures are qui te beni gn
unl ess di spl acement occurs. More seri ous
pel vi c fractures are those that di srupt the
Fi g. 13. Heal ed obl i que fracture of the ul nar shaft. Thi s type of fracture suggests that the mechani sm
of i njury was i ndi rect trauma (e.g., fal l i ng onto an outstretched hand) rather than di rect trauma (e.g.,
parryi ng a bl ow).
161
pel vi c ri ng through the rami or at the pubi c
symphysi s, wi th associ ated di sl ocati on of
the sacroi l i ac joi nt. The mechani sm of i njury
i n these cases tends to be anteri or-posteri or
crushi ng, l ateral compressi on, or verti cal
sheari ng force. Compl i cati ons are usual l y
seri ous and woul d l i kel y be l i fe-threateni ng
i n the absence of modern medi cal treatment.
A fracture-di sl ocati on of the hi p occurs when
the head of the femur i s dri ven through the
oor of the acetabul um. Thi s i s usual l y the
resul t of a heavy bl ow upon the l ateral
femur, due to a seri ous fal l or a si mi l ar
i mpact (e.g., vehi cul ar trauma i n cl i ni cal
cases). The i njury tends to commi nuti on and
seri ous compl i cati ons. A poorl y understood
l esi on that may resul t from the i ncompl ete
and temporary di sl ocati on of the hi p i s the
acetabul ar ange l esi on, whi ch appears as a
atteni ng of the superoposteri or ri m of the
acetabul um (Knowl es, 1983). Osteoarthri ti s
i s a common sequel to any i njury that i n-
vol ves the acetabul um.
Femur
Cl i ni cal data i ndi cate that fractures of the
femoral neck and trochanteri c regi on are
very common i n the el derl y and are seri -
ousl y di sabl i ng. Femoral neck fractures are
often a consequence of osteoporosi s and
therefore appear most often among ol der
femal es, al though physi cal acti vi ty duri ng
the reproducti ve years (i .e., age 15 to 45)
di mi ni shes si gni cantl y the l ong-term ri sk
of femoral neck fractures (strom et al .,
1987). When secondary to osteoporosi s, femo-
ral neck fractures may resul t from very mi l d
trauma, such as a stumbl e. They usual l y are
due to rotati onal force and cause l ateral
rotati on and upward di spl acement of the
shaft. Avascul ar necrosi s i s a seri ous compl i -
cati on of femoral neck fracture and i s caused
by damage to vessel s i n the neck that suppl y
the femoral head. The resul t i s that the
bl ood suppl y to the head may rel y overl y on
vessel s i n the l i gamentum teres, whi ch i s
onl y one of three routes of bl ood suppl y and
whi ch i s usual l y i nadequate on i ts own.
Necrosi s i s usual l y suffi ci entl y advanced
wi thi n 2 to 6 months posti njury that the
head col l apses. Unl ess ri gi dl y i mmobi l i zed,
femoral neck fractures are prone to non-
uni on, wi th avascul ar necrosi s bei ng the
most i mportant contri butor. Osteoarthri ti s
i s another common sequel and may be due to
mechani cal damage at the ti me of i njury,
i mpai rment of bl ood suppl y to the basal
l ayer of arti cul ar carti l age, and/or to mal -
al i gnment of a uni ted fracture. An i mpacted
abducti on fracture of the femoral neck oc-
curs l ess commonl y, but i t usual l y uni tes
wi thout surgi cal i nterventi on and may be
compl i cated onl y by sl i ght shorteni ng of the
l i mb and possi bl y by arthri ti s.
Fractures of the trochanteri c regi on (i .e.,
roughl y between the greater and l esser tro-
chanters) are common cl i ni cal l y but are not
l i kel y to be observed i n archaeol ogi cal popu-
l ati ons because they are al most al ways seen
i n adul ts over 75 years of age. Decreased
physi cal acti vi ty among ol der i ndi vi dual s i s
l i kel y a contri buti ng factor (Ni l sson et al .,
1991), further l i mi ti ng thei r occurrence i n
past popul ati ons who fol l owed tradi ti onal ,
nonmechani zed, l i feways.
Femoral shaft fractures are often due to
severe di rect or i ndi rect trauma. They may
occur at any l ocati on on the shaft and may
be of any fracture type. They are compl i -
cated by si mul taneous hi p di sl ocati on; arte-
ri al damage that can compromi se the vi abi l -
i ty of the l i mb; nerve damage, especi al l y to
the sci ati c nerve; and del ayed, mal -, or non-
uni on. Four months i s consi dered the aver-
age heal i ng ti me i n cl i ni cal cases of shaft
fractures. Associ ated deformi ty of shaft frac-
tures tends to be shorteni ng or angul ati on,
the l atter havi ng a tendency to faci l i tate
devel opment of osteoarthri ti s at the knee.
Supracondyl ar fractures of the femur are
more or l ess transverse and l ocated just
above the epi condyl ar regi on. Mal uni on i s
not a common sequel i n cl i ni cal cases where
there has been proper medi cal treatment
but i s a possi bl e compl i cati on i n earl i er
ti mes i f the knee coul d not be kept i mmobi -
l i zed for 2 to 3 weeks. Condyl ar fractures are
uncommon, but when these do occur they
are al most al ways due to di rect trauma. The
severi ty of the fracture can range from an
undi spl aced crack to compl ete separati on of
a condyl e wi th marked upward di spl ace-
ment. I n the absence of treatment, a di s-
pl aced fracture i s l i kel y to heal out of al i gn-
ment and osteoarthri ti s of the knee joi nt i s a
162
probabl e consequence. Occasi onal l y a trans-
verse supracondyl ar fracture combi nes wi th
a condyl ar fracture and forms a T-shaped
fracture l i ne that spl i ts apart the two con-
dyl es.
Patella
Fractures of the patel l a may be caused by
di rect or i ndi rect trauma. I ndi rect trauma
causes an avul si on fracture, usual l y a cl ean,
transverse separati on of the bone, due to the
sudden and vi ol ent contracti on of the quadri -
ceps muscl e. I n contrast, di rect trauma from
a fal l or a bl ow onto the patel l a tends to
cause a crack fracture or a commi nuted
fracture. Undi spl aced crack fractures tend
to heal wi thout compl i cati on because the
fragments are hel d i n posi ti on by the aponeu-
rosi s of the quadri ceps muscl e, but fractures
that i nvol ve separati on of the fragments and
those that are commi nuted wi l l produce an
i rregul ar arti cul ar surface unl ess surgi cal l y
repai red, and osteoarthri ti s i s then an obvi -
ous sequel .
Tibia and bula
I njuri es to the knee joi nt most commonl y
i nvol ve the meni sci and l i gaments, not bones,
and therefore there may be no evi dence of
trauma other than soft ti ssue ossi cati on
after l i gament strai n or tear, or avul si on of
the ti bi al spi ne from i njury to the cruci ate
l i gaments. When fractures do occur around
l ower l i mb joi nts they tend to affect the
ankl e, not the knee. Cl i ni cal l y, the bones
formi ng the ankl e are i njured more often
than any other bone except the di stal radi us.
I sol ated fractures of the mal l eol us of the
ti bi a or bul a are especi al l y common, and
occur wi th or wi thout di sl ocati on of the
tal us. The usual mechani sm of i njury for
these i s ei ther abducti on and/or l ateral rota-
ti on for fractures of the l ateral mal l eol us of
the bul a; and adducti on for fractures of the
medi al mal l eol us of the ti bi a. Si mul taneous
fractures of both mal l eol i are l ess common.
Verti cal compressi on forces can l ead to frac-
ture of the anteri or margi n of the di stal
ti bi a, or, i f severe, fragmentati on of the
di stal ti bi al arti cul ar surface, the l atter i n-
jury bei ng prone to osteoarthri ti s. Fractures
and di sl ocati ons at the ankl e are often com-
pl i cated by l i gament damage, whi ch coul d
be i denti abl e i n archaeol ogi cal skel etons
due to soft ti ssue ossi cati on.
Most di aphyseal fractures of the l eg i n-
vol ve both the ti bi a and bul a. I f the mecha-
ni sm of i njury i s an angul ar force, i t wi l l l ead
to transverse or short obl i que fractures of
the shafts at roughl y the same l evel . I f the
i njury i s due to a rotati onal force, spi ral
fractures wi l l resul t and wi l l occur at di ffer-
ent l evel s i n the two bones. Di stal ti bi al
shaft fractures, i .e., above the medi al mal l eo-
l us, are commonl y accompani ed by proxi mal
bul ar shaft fractures. Conservati ve treat-
ment of ti bi al shaft fractures i s to manual l y
reduce the fracture and to mi ni mi ze wei ght-
beari ng on the l i mb. I mmobi l i zati on for 2 to
3 weeks i s recommended i n cases of stabl e
fractures, but for up to 6 weeks i f the i njury
i s l i kel y to be di spl aced; ful l uni on may take
as l ong as 4 months. Mal uni on i s rare i n
cl i ni cal cases but common archaeol ogi cal l y
because of the greater l i kel i hood of fractures
remai ni ng unreduced and the di ffi cul ty of
i mmobi l i zi ng the l eg. Because i t i s so cl ose to
the surface of the ski n, the ti bi al shaft i s the
most common si te of an open (compound)
fracture and hence i nfecti on from contami na-
ti on. I nfecti on can al so l ead to nonuni on. A
bul ar shaft fracture i s not consi dered seri -
ous by most cl i ni cal practi ti oners because i t
uni tes readi l y and i s of such l i ttl e functi onal
i mportance that surgi cal removal of a por-
ti on of the shaft i s not onl y tol erabl e but i s
advocated when the bone acts as a strut,
di stracti ng the fragment ends of a ti bi al
fracture and promoti ng nonuni on. Thus, bu-
l ar shaft fractures are expected to be rare i n
the archaeol ogi cal record but when observed
they may be heal ed wi th deformi ty.
Fractures of the ti bi a at the knee joi nt are
uncommon. Cl i ni cal l y, the most common i s
fracture of the l ateral ti bi al condyl e, caused
by a l ateral force agai nst the knee such as
experi enced by footbal l pl ayers or by pedes-
tri ans struck by a vehi cl e bumper. I f the
arti cul ar surface i s fragmented i n the i njury
then osteoarthri ti s i s a predi ctabl e sequel .
Hand, wrist, foot, and ankle
Accordi ng to cl i ni cal evi dence, the i rregu-
l ar bones most commonl y fractured are the
scaphoi d and tri quetral i n the hand, and the
cal caneus i n the foot (Adams, 1987). Frac-
163
ture of the scaphoi d tends to occur i n young
adul ts, usual l y due to i ndi rect trauma from
a fal l onto an outstretched hand. The typi cal
i njury i s a transverse break through the
wai st of the bone, and shoul d not be con-
fused wi th a congeni tal l y bi parti te scaphoi d.
Scaphoi d fractures are accompani ed by a
hi gh frequency of compl i cati ons, i ncl udi ng
del ayed uni on, nonuni on, avascul ar necro-
si s, and osteoarthri ti s. I njury to the tri que-
tral al so usual l y resul ts from a fal l , but
causes a chi p fracture on the dorsal surface
of the bone. Al most al l cal caneal fractures
are caused by a fal l from a hei ght onto the
heel s, such as occurs as an occupati onal
hazard among bui l ders and wi ndow cl ean-
ers (Wel l s, 1976) and a resul t of mi sadven-
ture among parachuti sts, hi kers, and rock
cl i mbers, for exampl e. Afal l from a tree, cl i ff,
or roof of a dwel l i ng i s a possi bl e cause of
such i njury i n past popul ati ons, al though i t
has been suggested that these i njuri es woul d
be uncommon i n fal l s of l ess than 4 m (Wel l s,
1976). The fracture may be observed as a
spl i t or crack i n the subtal ar tuberosi ty, but
more often the arti cul ar surface of the cal ca-
neus fai l s to wi thstand the stress and re-
sul ts i n a crush i njury. Fracture l i nes may
radi ate to the front and appear al so on the
cal caneo-cuboi d joi nt. Associ ated crush frac-
ture of l ower thoraci c or upper l umbar verte-
brae may be noted. The usual compl i cati on
of cal caneal fracture i s osteoarthri ti s. Frac-
tures of the tal us are rel ati vel y uncommon.
Metacarpal s, metatarsal s, and phal anges
are common si tes of traumati c i njury. Meta-
carpal s are often fractured due to l ongi tudi -
nal compressi on i mpact such as from boxi ng.
I f the fracture l i ne enters the joi nt then
osteoarthri ti s i s a l i kel y compl i cati on. The
neck and di stal shaft of metacarpal s al so are
prone to transverse or obl i que fractures,
often compl i cated by di spl acement. Manual
phal anges tend to exhi bi t spi ral or trans-
verse fractures of the shaft or obl i que frac-
tures of the base. Commi nuti on i s most
l i kel y i n the di stal phal anges. Di sl ocati ons
of phal anges are mai nl y due to forced hyper-
extensi on, but at l east one archaeol ogi cal
exampl e appears to resul t from forced adduc-
ti on wi th associ ated teari ng of the medi al
col l ateral l i gament of the i nterphal angeal
joi nt that made reducti on i mpossi bl e and l ed
to mal al i gnment of the joi nt and subsequent
ankyl osi s (Dri er, 1992). Metatarsal shafts
may exhi bi t transverse or obl i que fractures
(Fi g. 14). The base of the fth metatarsal i s a
common si te of avul si on fracture caused by a
twi sti ng i njury. The pedal phal anges, par-
ti cul arl y that of the great toe, often suffer
commi nuted crushi ng i njuri es from di rect
trauma.
INTERPRETING THE ULTIMATE CAUSE
OF INJURY
Once the i njury has been descri bed, i ts
proxi mate cause determi ned, and any com-
pl i cati ons i denti ed, the ul ti mate cause of
the trauma can be eval uated. Thi s eval ua-
ti on must consi der three types of i nforma-
ti on: 1) the characteri sti cs of the fracture
i tsel f; 2) the skel etal pattern of trauma i n
the i ndi vi dual and the popul ati on; and 3) the
Fi g. 14. Heal ed fracture of the l eft fth metatarsal ,
wi th the unaffected contral ateral el ement for compari -
son. Al though the fracture l i ne i s not cl ear, the rotati on
of the head i ndi cates a spi ral fracture, probabl y due to a
combi ned angul ar/rotati onal force.
164
soci al , cul ture hi stori cal , and/or envi ronmen-
tal context of the human remai ns, i ncl udi ng
the presence of arti facts. Cl i ni cal research
has consi dered the rol e of many vari abl es i n
tr auma causati on (e.g., Agar wal , 1980;
strom et al ., 1987; Barber, 1973; Bjornsti g
et al ., 1991; Buhr and Cooke, 1959; Busch et
al ., 1986; Cogbi l l et al ., 1991; Donal dson
et al ., 1990; Fi fe and Baranci k, 1985; Fi fe et
al ., 1984; Garraway et al ., 1979; Gri mm,
1980; Johansson et al ., 1991; Jonsson et al .,
1992; Jones, 1990; Knowel den et al ., 1964;
Madhock et al ., 1993; Ni l sson et al ., 1991;
Pri nce et al ., 1993; Ral i s, 1986; Sahl i n, 1990;
Shaheen et al ., 1990; Zyl ke, 1990) and pro-
vi des val uabl e ai ds for the i nterpretati on of
fractures i n anti qui ty, parti cul arl y wi th re-
gard to skel etal patterni ng and the contexts
of i njury.
The use of the characteri sti cs of the frac-
ture i tsel f to i denti fy the mechani sm of
i njury and poi nt to l ogi cal causes of fracture
can be i l l ustrated by reference to a parti cu-
l arl y probl emati c i nterpretati on of trauma,
that of the parry fracture. Al though thi s
i njury has been descri bed vari ousl y as a
si mpl e mi dshaft fr actur e (Lovejoy and
Hei pl e, 1981), the resul t of a bl ow to an
uprai sed arm duri ng a ght (Janssens, 1970),
or the fracture of both radi us and ul na
(Wel l s, 1964), the term i s i nterpreted by
many schol ars to i denti fy the i nvol ved bone
(the ul na), i ndi cate the l ocati on of the i njury
(on the shaft), and i mpl y speci c soci al and
cul tural ci rcumstances, i .e., i nterpersonal
coni ct. A true parry fracture woul d i ndeed
be caused by a di rect bl ow to the forearm,
but a proper di agnosi s must rel y on descri p-
ti ons of the fracture l ocati on, fracture type,
bones i nvol ved, apparent di recti on of force,
and evi dence of any compl i cati ons. Al though
si mpl e transverse fractures of the ul na are
conventi onal l y vi ewed as parry fractures, a
consi derati on of fracture types and mecha-
ni sms of i njury i ndi cates that a parry frac-
ture coul d be i ndi cated by ei ther a trans-
verse l i ne or a commi nuti on; the fracture
coul d be cl osed or open; and the radi us coul d
be affected i n addi ti on to the ul na. The term
parry fracture does not appear i n the cl i ni -
cal l i terature on fracture descri pti on, eti ol -
ogy, and treatment (e.g., Adams, 1987), and
other terms commonl y used i n orthopedi c
medi ci ne shoul d therefore be used to de-
scri be rel evant i njuri es. An exampl e i s the
Monteggi a fracture of the ul na wi th associ -
ated di sl ocati on of the proxi mal radi us, de-
scri bed previ ousl y i n thi s paper. Al though
thi s term descri bes the type of fracture, i t
does not speci fy a cause. I n fact, thi s i njury
can be caused by a di rect bl ow to the poste-
ri or ul nar shaft or by the i ndi rect trauma of
a forced pronati on i njury. A fati gue fracture
mi ght al so mani fest as a si mpl e transverse
break, as i l l ustrated by the case of a mi d-
shaft ul nar fracture caused by the repeated
physi cal stress of forki ng manure (Ki tchi n,
1948). Thus, al though the preval ence of
parry fractures i s often reported i n pal eo-
pathol ogi cal studi es i t i s not al ways cl ear
whether al l or any of the i njuri es actual l y
resul ted from parryi ng a bl ow.
These probl ems wi th the di agnosi s of parry
fractures are compounded i n pal eopathol ogi -
cal i nterpretati ons of soci al order, parti cu-
l arl y vi s a vi s gender rel ati ons (for a cri -
ti que, see Mafar t, 1991). Wi thout other
supporti ng evi dence, Wood-Jones (1910) as-
cri bed femal e sex to anci ent Nubi an skel -
etons that di spl ayed forearm fractures si nce
he thought the cause of the fractures was
spousal abuse by Nubi an men armed wi th
heavy staffs. Wel l s referred to forearm frac-
tures among the anci ent Nubi ans as i ndi cat-
i ng short tempers and aggressi ve conduct
that i mpl i ed wi fe beati ng or a general l y l ow
status of women (Wel l s 1964). Hi s accompa-
nyi ng fracture descri pti ons, however, refer
onl y to the fact that the i njury appeared i n
the mi d- or l ower shaft of the ul na, or
affected the ul na and the radi us. Ul nar
fractures among the Cro-Magnon were si mi -
l arl y i nterpreted to i ndi cate an aggressi ve
nature (Zi vanovi c, 1982); however, the ac-
companyi ng photograph and x-ray of one
such i njury shows a spi ral fracture, wi th
rotati on i n the di stal aspect. Spi ral frac-
tures, i n parti cul ar, are unl i kel y to resul t
from a di rect bl ow, but rather from a twi st-
i ng, forced pronati on i njury, such as i n a fal l .
Whi l e features of the fracture i tsel f may
i denti fy the mechani sm of i njury, the skel -
etal pattern of fractures i n an i ndi vi dual
may al so hel p to cl ari fy the probabl e causes
of trauma. Cl i ni cal l y, the ul na and radi us
are fractured more commonl y than are any
165
other skel etal el ements, but the cause of
i njury vari es and rarel y i s due to assaul t. A
comprehensi ve study of l ong bone fractures
i n Medi eval Bri tai n al so i ndi cates that the
radi us and ul na are the bones most com-
monl y affected, l i kel y due to fal l s and other
mi shaps rather than vi ol ence (Grauer and
Roberts, 1996). I ndeed, fractures of the cra-
ni um, ri bs, or hands are more l i kel y to
i ndi cate trauma due to i nterpersonal vi o-
l ence than are fractures to the forearm.
I njuri es that are consi dered to have a hi gh
speci ci ty for a cl i ni cal di agnosi s of assaul t
are fractures of the skul l (especi al l y the
nasal and zygomati c bones and the man-
di bl e); and posteri or ri b fractures, vertebral
spi nous process fractures, and fractures of
hand and foot bones, whi ch can resul t from
the di rect trauma of punches or ki cks. Occa-
si onal l y the pal mar surfaces of the manual
phal anges wi l l exhi bi t heal ed or unheal ed
cutmarks, ori gi nati ng as defensi ve wounds
i ncurred as a vi cti m of a kni fe or sword
attack. Al though fractures that pass al ong
suture l i nes are common on subadul t skul l s,
the exposure of di pl oe i n i ntersutural perfo-
rati ons i s a key i ndi cator of antemortem
trauma. I n addi ti on, metaphyseal l esi ons,
transverse fractures of the scapul ar acro-
mi on, and sternal fractures are consi dered
i ndi cati ve of chi l d abuse i n cl i ni cal cases and
may resul t from shaki ng forces rather than
di rect bl ows (Appl eton, 1980; Bri smar and
Tuner, 1982; Fi sher et al ., 1990; Fonseka,
1974; Gayford, 1979; Kl ei nman, 1987; Shep-
herd et al ., 1990). Accordi ng to cl i ni cal prac-
ti ti oners, the most speci c ndi ng of physi -
cal abuse i n both adul ts and chi l dren i s
mul ti pl e i njuri es at di fferent stages of heal -
i ng (Mapl es, 1986; Wal ker et al ., 1997;
Wi l ki nson and Van Wagenen, 1993).
5
Mul -
ti pl e but si mul taneous fractures, i n con-
trast, may represent acci dental trauma, as
demonstrated by the case of a Neol i thi c i nt
mi ner i n Bel gi um who suffered numerous
fractures and apparentl y di ed of hi s i njuri es
when the roof of the mi ne col l apsed on top of
hi m (Knowl es, 1983).
Patterns of fractures wi thi n a popul ati on
may al so be i nformati ve. Cl i ni cal l y, ol der,
postmenopausal femal es have more frac-
tures than do any other age/sex group due to
the i nuence of osteoporosi s as a predi spos-
i ng factor i n fracture from mi nor, often
i ndi rect, trauma, and thi s pattern i s paral -
l el ed i n an earl y 20th century skel etal col l ec-
ti on (Mensforth and Lati mer, 1989). When
ol der femal es are excl uded, cl i ni cal fracture
rates are greatest among i ndi vi dual s youn-
ger than 26 years of age and tend to be
determi ned by thei r acti vi ti es. Age al so i nu-
ences the skel etal pattern of i nvol vement.
Femoral neck fractures, for exampl e, occur
commonl y i n ol der adul ts but rarel y i n chi l -
dren.
Features of the physi cal envi ronment al so
have been shown to i nuence the frequency
and nature of trauma. For exampl e, adverse
weather condi ti ons (e.g., snow and i ce) and
i rregul ar l andscapes i ncrease fracture ri sk
from fal l s, whi l e reduced wi nter dayl i ght
hours i n northern l ati tudes i ncrease frac-
ture ri sk from mi shaps due to l i mi ted vi si bi l -
i ty. Decreased sunl i ght al so may i mpai r
cal ci um absorpti on and l ead to fractures
secondary to osteoporosi s or ri ckets, and
di etary i nadequaci es of vi tami n C or cal ci um
may i ncrease the ri sk of pathol ogi cal frac-
tures.
The soci ocul tural context of i njuri es must
al so be consi dered. Cl i ni cal evi dence over-
whel mi ngl y i ndi cates, for exampl e, that most
fractures are due to dai l y acti vi ty rather
than i nter per sonal vi ol ence or unusual
events. Tradi ti onal l y, most fractures i n fe-
mal es occur i n the home whi l e most frac-
tures i n mal es occur at work or duri ng
sports, al though thi s trend vari es accordi ng
to country, i ncome l evel , occupati on, and
age. Hi gh fracture ri sks exi st i n occupati ons
that have been general l y restri cted to men,
such as agri cul ture, mi ni ng, forestry, and
constructi on. I n devel opi ng nati ons, house-
hol d work such as carryi ng water and l oads
of rewood pose hi gh fracture ri sks for
women, as do many farmi ng acti vi ti es en-
gaged i n by both sexes. Technol ogy-based
transportati on, ei ther mechani zed (e.g., au-
tomobi l es) or unmechani zed (e.g., bi cycl es
and horse-drawn wagons), al so carri es i ts
own fracture ri sk. Gi ven ci rcumstances such
5
For further descri pti ons and di scussi ons of the skel etal evi -
dence for i nterpersonal coni ct, the reader i s referred to Troubled
Times: Osteological and Archaeological Evidence of Violence,
edi ted by D. Marti n and D. Frayer and forthcomi ng from Gordon
and Breach publ i shers.
166
as these, the trauma caused by acti vi ty or
occupati on may be i ndi sti ngui shabl e from
that due to i nterpersonal vi ol ence (Smi th,
1996; Wakel y, 1996).
Fi nal l y, hi stori cal records and an under-
standi ng of the soci ocul tural context of the
i njuri es can benet thei r i nterpretati on, such
as the expl anati on of fractures due to occupa-
ti onal acci dent duri ng the 1856 constructi on
of the Grand Trunk Rai l road i n Canada
(Ji menez, 1994). Several cases of i nterpreta-
ti on have successful l y rel i ed on such i nforma-
ti on, such as the i denti cati on of strangul a-
ti on from hyoi d fractures and of hangi ng and
decapi tati on from vertebral i njuri es (Angel
and Cal dwel l , 1984; Wal dron, 1996), and the
comprehensi ve anal yses of trauma eti ol ogy
i n an abori gi nal popul ati on of the Canadi an
northwest coast (Cybul ski , 1992), i n prehi s-
tori c popul ati ons of the Ameri can mi dwest
(Mi l ner, 1995), and among sol di ers of the
14th century battl e of Vi sby (I ngel mark,
1939; Knowl es, 1983). Often the most com-
pel l i ng evi dence for i nterpersonal vi ol ence
l i es i n the presence of arti facts or other
physi cal evi dence of vi ol ence. Pr ojecti l e
poi nts embedded i n bone or recovered from
the abdomi nal cavi ty are di agnosti c of at
l east some traumati c events, and may poi nt
l ogi cal l y to the cause of other i njuri es as wel l
(e.g., Benni ke, 1985; Jurmai n, 1991; Smi th,
1996; Wal ker, 1989; and several papers i n
Owsl ey and Jantz, 1994).
CONCLUSIONS
Thi s revi ew of fracture types and of the
proxi mate and ul ti mate causes of i njury
i ndi cates that standardi zed descri pti ve pro-
tocol s can be used to i mprove pal eopathol ogi -
cal anal ysi s and i nterpretati on of trauma.
These protocol s shoul d i ncl ude i denti ca-
ti on of the skel etal el ement(s) i nvol ved; the
l ocati on of the i njury; i ts appearance; and
any evi dence for compl i cati ons of the i njury.
These descri pti ons thus serve as a basi s for
i nferences about the mechani sm of i njury,
from whi ch soci al , cul tural , or envi ronmen-
tal associ ati ons may then be exami ned. At-
tenti on to skel etal patterns, bi ol ogi cal fac-
tors such as age and sex, and vari abl es such
as physi cal and soci ocul tural envi ronments
al so i mproves the di agnosti c accuracy of any
i nterpretati ons. I n parti cul ar, the traumati c
effects of vi ol ence may be di ffi cul t to di sti n-
gui sh from those of hi gh-ri sk acti vi ti es or
occupati ons sol el y on the basi s of skel etal
evi dence. Al though the actual cause of
trauma di spl ayed by an archaeol ogi cal skel -
eton may remai n unknown, a quanti abl e
descri pti on based on speci c termi nol ogy,
suppl emented by photographi c and radi o-
graphi c i mages of the fracture, and cl earl y
pl aced i n an i ndi vi dual , popul ati onal , soci o-
cul tural , and physi cal context wi l l enabl e
others to eval uate a researcher s i nterpreta-
ti on of the i njury.
ACKNOWLEDGMENTS
I thank Carol yn Pri ns, who sel ected and
eval uated the cl i ni cal case studi es and who
conducted some of the l i brary research; the
Uni versi ty of Al berta Hospi tal , whi ch pro-
vi ded the cl i ni cal fracture data; Margaret
Judd, who provi ded hel pful di scussi on and
numerous references; Ben Lees, who sup-
pl i ed useful i nformati on on rearms; and
Scott Haddow, who assi sted wi th pri nti ng of
photographs. I have al so benetted greatl y
from di scussi ons wi th Robert Jurmai n and
Lynne Ki l gore and from suggesti ons made
by the revi ewers of thi s paper. Thi s research
was supported by a grant from the Soci al
Sci ences and Humani ti es Research Counci l
of Canada.
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