The Comparison of Three Cases of Femoral Shaft Fractures
Laura Sophia Schwarz, German Archaeological Institute, Berlin, Katharina Fuchs, Christian-Albrecht University, Kiel, Julia Gresky, German Archaeological Institute, Berlin
Introduction
Today, femoral shaft fractures are medical emergencies which can be easily dealt with. Modern narcotics enable surgeons to reduce the fracture
without immense pain to the patient and the fractured site can be stabilized by screwing or implanting plates.
In archaeological contexts, fractures of the femoral shaft are often very
spectacular, especially when no attempt was made to reduce them. Research was conducted into three cases of femoral shaft fractures, which had
been survived and appeared to be well healed, two from the Bronze Age
in Russia and one from the Scythian period in Kazakhstan.
Fractures of the Femur – medical aspects
Methods
Fractures of the femur are widely known. Three main areas can be affected
by fractures: the femoral neck, the shaft and the distal part of the femur
with or without joint involvement. The most common fracture site is the
femoral neck mainly because of the less dense cortical bone that is also
easily weakened by osteoporosis. Fractures of the femoral shaft are more
rare because this requires the impact of severe bending and torsional
forces.
Several forms of fractures can be outlined: 1. Transverse fractures 2. Short
or long oblique or torsion fractures with or without appearance of torsion
wedge 3. Comminuted fractures.
Typical features of fractures of the femoral shaft are: Shortening, dislocation with flexion, abduction/adduction and external rotation of the proximal fragment.
Besides other severe complications, the major issue is a large amount of
blood loss, which can lead to massive haematoma. Myositis ossificans
traumatica and secondary arthrosis due to malposition are also frequently
described.
Three cases of femur fractures, two from the Bronze Age in Russia and one
from the Scythian period in Kazakhstan were investigated (see table). For
sex and age estimation of the individuals the methods outlined in Buikstra and Ubelaker (1994)3 were used. X-Ray was conducted using Faxitron
43805 N by Hewlett-Packard at the German Archaeological Institute, Berlin, the CT-Scans were conducted by the radiological section of the Charité Klinikum Berlin Mitte, using the Toshiba Aquillion One© CT, as well
as the DICOM-reader© software. For analysis of the X-Ray and CT-Scans
the recommendations of Roberts (1988)13 were used for orientation. For
description of the fractures the features of the LARA (length, apposition,
rotation, angulation) method as proposed by Lovell (1997)5 was used. For
light microscopic analyses thin-ground sections were prepared by the
technique described by Schultz and Brandt15,17,18. Modern clinical studies
and reports about paleopathological cases were searched for information
about type and localisation of fracture, age and sex distribution, causes,
healing and complications.
Fig. 2 a/b Overview (a) and CT-Scan (b) of the Femur from the site of Mayemer, lateral
Fig. 1 a/b Overview (a) and CT-Scan (b) of the Femur from the site of Kudachurt, anterior
Case 1
Individual sex/age
Site/Dating/Preservation
Location of fracture
Simple/Compound
Kind of fracture
Force/impact
Rotation
Lateral view (angulation)
Anterior-posterior view (angulation)
Shift of the distal fragment
Further associated fractures
Complications
Male, 30-45 years
Kudachurt/Middle-Late Bronze Age/75-100%
middle diaphysis of right femur
simple
oblique
indirect
internal 12°
posterior 2°
medial 12°
posterior 1.8 cm
fracture of the left parietal bone
Mal-union, Myositis ossificans
Fig. 3 a/b Overview depiction of the Femur from the site of Konstantinovskij (a. a-p, b. m-l)
Case 2
Case 3
Female, 35-45 years
Mayemer/Scythian/50-75%
middle diaphysis of left femur
simple
comminuted
direct
external 25°
posterior (middle fragm.) 34°, anterior (distal fragm.) 34°
lateral 2°
posterior 5.1 cm
fracture of the right patella
Mal-union, Myositis ossificans, Arthrosis
Male, 50-65 years
Konstantinovskij/Late Bronze Age/ <50%
distal diaphysis of right femur
simple
oblique or comminuted
indirect
external 22°
posterior (middle fragm.) 48°, anterior (distal fragm.) 52°
medial 10°
posterior 4.7 cm
fracture of the left talus
Mal-union, Arthrosis
Tab. 1 Overview over the results from the examined Femurs
Histological observations
Discussion
Histology was undertaken to get a better idea of the origin of the
newly built fusiform structures next to the fractured area on the
femur of Majemer on the dorsal side and on the femur of Kudachurt on the ventral-lateral side. Macroscopically, it resembled
Myositis ossificans traumatica, subperiosteal haematoma or periosteal osteosarcoma. Osteosarcoma can be excluded because
it is very rare and has another pattern of growth (the calcification
originates in the center and diminishes to the periphery). A subperiosteal haematoma is directly attached to the intact original
bone surface and the trabeculae have a radiating or
arcade-like structure15,16, 20.
Myositis ossificans is organized in three layers, an outer
compact layer, a middle zone
of trabecular bone and an
internal zone with large cavities19 . This appearance is
very obvious in the case of Fig. 4 Thin ground section (60 µm) of fusiform
Kudachurt where the cap- structure of the ventral surface of Femur case 1
like thickening shows different zones. Beneath the outer compact layer a more trabecular layer is attached which is separated
from the original compact bone (blue dot) by a huge cavity (red
dot). The borders between old and new bone structures are not
distinct due to the long period of healing. It fits with the findings
of Herzog (1944)4 that the exostoses of Myositis ossificans on the
ventral part of the femur tend to be attached more broadly to
the bone than on the dorsal part of the femur. Therefore they can
easily be confused with subperiosteal haematoma. In the case of
Majemer it is not possible to diagnose between subperiosteal haematoma and Myositis ossificans because the newly built bone
formation is completely remodeled.
The three cases of femoral shaft fractures described here are in a group of rather rare fractures that nowadays only make up 5% of all femoral fractures. This type
of fracture is also only rarely described in the palaeopathological literature6, 7, 8,10,12,19. The rarity and the lack of consistency of particular features make the evaluation of this kind of fracture difficult.
The main thing all the fractures have in common is the positioning. In modern cases the location on the shaft was observed mostly in the middle third 2. The
same is observable in our cases and all cases in palaeopathological literature.
Age distribution for acquiring femoral fractures: Studies of modern cases indicate two age related peaks for acquiring fractures: in the early years 15-24 and
over 7514. This observation was also confirmed by the study of Ng et al. (2012)9. In at least two of our three cases and in six of eight individuals in the literature
they died in adult age, with healed fractures, acquired at least several vears before death. In Case 3 of our cases and the two mature cases from the literature the
exact dating of the fracture is not possible because of long-term survival. In all of the palaeopathological cases in contrast to modern cases there is a tendency
towards the younger age and no second peak in senile age could be confirmed.
Sex distribution concerning femoral fractures: The study of modern cases by Ng et al. (2012)9 showed a connection between sex and age of people with femur
shaft fractures: Males had a first trauma at the mean age of 31.2 years, in females fractures appeared at the age of 59.7 years. In our three cases and in seven cases in the literature, there is no evidence for a connection between sex and age.
Causes: In the recent younger group displaying fractures the cause was mostly found to be due to high energy impacts (eg. motorvehicle accidents), as well as
falls from heights or direct trauma. In the cases of the older group low energy impacts were already found to be sufficient to break the shaft1,2. In only one case
in the literature, was a probable fall from height mentioned as a possible cause9. In our three cases, falls from height and direct force are possible sources of trauma. The question of the impact of horse riding and the accompanied dangers of falling or being kicked by a horse must be considered but cannot be confirmed.
In modern cases, polytraumata have been found in up to 95% of fractures2 which provides the severe forces leading to this particular fracture. In all of our cases,
additional fractures (cranial, patella and talus fracture) are present. One femur displayed an oblique fracture, two most probably a comminuted fracture, leading
to the assumption that the kind of trauma was indirect in one and direct in two cases.
Healing and Complications: In all of our cases and in 13 of 14 cases in the literature, the fractures are well healed (in one case only partly healed6). In modern
medically treated fractures non-union appeared in 14.7%2. In all of the palaeopathological cases malunion emerged, most likely due to the lack of reduction,
whereas malunion was found in only 8% of the modern cases. Osteomyelitis has been discovered in 1% of the modern treated cases and in one of the 14 palaeopathological cases. This is most likely due to the nature of the fracture as being simple and not compound5. In modern cases secondary arthrosis seems to
have only minor effects11. In two of our cases severe arthrosis was present, due to malposition and shortening of the fractured femur. Most probably, in palaeopathological cases, arthrosis as a complication was quite common but is only mentioned in one case8. However, Myositis ossificans traumatica is mentioned as a
complication in four cases in the palaeopathological literature and occurs in two of our three cases. Although the fractures were survived for a long time, in one
case a Myositis ossificans traumatica could be proved by histology.
Unfortunately, the lack of ancient cases and less detailed information in the publications of modern and ancient samples makes it difficult to come to more detailed conclusions. None the less, most of the observations made in the modern samples can be seen in the ancient samples as well. Today complications like
mal- or non-union are rare but still to be found even with medical intervention.
1) Arneson, T.J.; Melton, L.J.; Lewallen, D.G.; O‘Fallon, W.M. (1988): Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res 234, pp. 188–194
2) Ciuvică, R.; Vasilescu, M.; Bordianu, A.; Cristea, S. (2013): Our experience in treating femoral diaphyseal fractures and their most common. In: Sports Medicine Journal / Medicina Sportivà 9 (3), pp. 2191-2197
3) Haas, J.; Buikstra, J.E.; Ubelaker, D.H.; Aftandilian, D. (1994): Standards for data collection from human skeletal remains. Proceedings of a seminar at the Field Museum of Natural History, organized by J. Haas. Fayetteville, Arkansas Archeological Survey Research Series 44
4) Herzog, G. (1944): Die primären Knochengeschwülste. In Rössle, R. (Ed.) Handbuch der speziellen pathologischen Anatomie und Histologie 9/1, Berlin, pp. 1-483
5) Lovell, J. (1997): Trauma analysis in Palaeopathology. Yearb Phys Anthropol 40, pp.139-170
6) Mann, R.W.; Hunt, D.R. (2013): Photographic regional atlas of bone disease. A guide to pathologic and normal variation in the human skeleton. 3rd ed. Springfield.
7) Mitchell, P.D. (2006): Trauma in the Crusader period city of Caesarea: a major port in the medieval eastern Mediterranean. Int J Osteoarchaeol 16 (6), pp. 493-505
8) Neri, R.; Lancellotti, L. (2004): Fractures of the lower limbs and their secondary skeletal adaptations: a 20th century example of pre-modern healing. Int J Osteoarchaeol 14 (1), pp. 60-66
9) Ng, A.C.; Drake, M.T.; Clarke, B.L.; Sems, S.A.; Atkinson, E.J.; Achenbach, S.J.; Melton, L.J. (2012): Trends in subtrochanteric, diaphyseal, and distal femur fractures, 1984-2007. Osteoporos Int 23 (6), pp. 1721-1726
10) Ortner, D.J. (2003): Identification of pathological disorders in human skeletal remains. 2nded, London
11) Phillips, J.R.A.; Trezies, A.J.H; Davis, T.R.C. (2011): Long-term follow-up of femoral shaft fracture: Relevance of malunion and malalignment for the development of knee arthritis. Injury 42 (2), pp. 156-161
12) Prokopec, M.; Halman, L. (1999): Healed fractures of the long bones in 15th to18th century city dwellers. Int J Osteoarchaeol 9 (5), pp. 349-356
13) Roberts, C.A. (1988): Trauma and Its Treatment in British Antiquity: An Osteoarchaeological Study of Macroscopic and Radiological Features of Long Bone Fractures from the Historic Period with a Comparative Study of Clinical Radiographs. University of Bradford
14) Salminen, S.T.; Pihlajamäki, H.K.; Avikainen, V.J.; Böstman, O.M. (2000): Population based epidemiologic and morphologic study of femoral shaft fractures. Clin Orthop Relat Res 372, pp. 241-249
15) Schultz, M. (2001): Paleohistopathology of bone: a new approach to the study of ancient diseases. Am J Phys Anthropol 33, pp. 106–147
16) Schultz, M., (2003): Light Microscopic Analysis in Skeletal Paleopathology. In: Ortner, D.J. (Ed.) Identification of Pathological Conditions in Human Skeletal Remains. San Diego, pp. 73-109
17) Schultz, M. (2011): Light microscopic analysis of macerated pathologically changed bones. In: Crowder, C., Stout, S., (Eds.), pp. 253-296
18) Schultz, M.; Drommer, R. (1983): Möglichkeiten der Präparatherstellung aus dem Gesichtsschädelbereich für die makroskopische und mikroskopische Untersuchung unter Verwendung neuer Kunststofftechniken. In: Hoppe, W. (Ed.), Experimentelle Mund-Kiefer-Gesichts-Chirurgie. Mikrochirurgische Eingriffe. Stuttgart,
pp. 95-97
19) Schultz, M.; Teschler-Nicola, M. (1987): Krankhafte Veränderungen an den Skeletten aus dem Karner der St. Martins-Kirche in Klosterneuburg, Niederösterreich Teil I-IV. Ann Naturhist Mus Wien
20) Van der Merwe, A.E; Maat, G.J.R; Steyn, M. (2010): Ossified haematomas and infectious bone changes on the anterior tibia. Histomorphological features as an aid for accurate diagnosis. Int J Osteoarchaeol 20(2), pp. 227-239
Acknowledgments:
We would like to thank A. Nagler, A. Gass,
R. Boroffka, A. Belinskij, B. Atabiev for the possibility to work with the material, as well as K. Tucker
for editing.
Further thaks goes to S. Künzel for her help and
support with the CT-Scans.
This work was sponsored by the Federal Ministry
of Education and Research, Germany as part of the
Silk Road Fashion Project