Casting A Wider Net: An Example of Care in a Prehistoric Context

Due to a number of factors I haven’t updated this blog for a while now, but that doesn’t mean that I am completely inactive.  A number of posts are upcoming, however they just may take a while to be published due to a number of other issues that mean this site takes a back seat (I have been blogging elsewhere though).  I do still keep an eye out on other osteologically and bioarchaeologically focused blogs (such as the fantastic triplet of sites that includes Bone Broke, Bodies and Academia and Powered By Osteons).  Occasionally I also scan the relevant journals for updates and news, printing articles of interest (and praying that they are open access when I click them!).

Today two such articles caught my eye on the always reliably diverse and interesting International Journal of Palaeopathology website.

The first, by Vairamuthu & Pfeiffer, discusses the possible differential diagnoses of a juvenile female whose skeletal remains display ‘pervasive bone wasting and fragile jaws’ (2018: 1).  The individual, known as Burial 2, was aged 16 years at death and located within a Late Archaic cultural context dating to roughly 3000 BP (Before Present). This cultural context at the Hind Site in Middlesex County, Ontario (Canada), represented a highly mobile society who practiced a seasonal and migratory foraging and hunting lifestyle.  Through careful anatomical study of the skeletal elements, including the patterns of bone wastage and growth, along with a thorough differential diagnoses investigation, the researchers conclude that the individual known as Burial 2 likely had Osteogenesis Imperfecta (type IV), a very variable type of the disease which predominately affects the skeletal system due to a lack of type I collagen in connective tissues.

Photograph taken from the original 1968 Late Archaic excavation in Middlesex County, Ontario. The site dates to roughly 3000 BP. Burial 2 (right) is a juvenile individual (aged at 16 years old at time of death), who has been sexed as a female, located next to the adult female Burial 3 (left) within the same grave. Both were in a flexed body position and facing each other. Image credit: Vairamuthu & Pfeiffer 2018: 3.

What really intrigued me about Vairamuthu & Pfeiffer’s study was the model of care discussion (2018: 6-7) which though exceptionally brief indicated the sociocultural background of modern individuals who live with Osteogenesis Imperfecta (OI) in its many forms:

A medical anthropological study that interviewed people of diverse socioeconomic and geographic backgrounds who have OI describes such individuals as small (22-45kg), and having a particular behavioral phenotype of ‘resilience’.  This phenotype is characterized as being bright, accomplished and often adventurous (Ablon 2003). (Emphasis mine).

It is good to see this being highlighted within the (impressive) osteological analysis of the human remains, of the 16-year-old female now identified through the modern moniker of ‘Burial 2’.  This was an individual who likely needed care and assistance in daily ambulation, along with the preparation of a soft food diet, transportation, hygiene, and various activities regarding upper limb strength (Vairamuthu & Pfeiffer 2018: 7).  Whilst reading through the paper I thought that the individual would make an interesting Bioarchaeology of Care case study, particularly so as the archaeological context is well documented and a number of other individuals representative of Burial’s 2 immediate temporal population are available for comparative analysis.

On a personal level this also reminded me of what a former orthopaedic consultant had mentioned to me previously regarding the hardiness of children after extensive skeletal trauma and surgical interventions, the fact that juveniles are far more resilient than is often expected of them by adults.

The second article by Gresky et al. (2018: 90) focused on a palaeopathological case study of a male aged 22-25 years at death, skeletally complete and excavated from a mound at the burial ground of Budyonnovsk 10 in the Stavropol region of southern Russia. The site itself dates from the Middle Bronze Age to some partial use of the mounds up until the late Middle Ages, however the archaeological context of Burial 14 dates to the Late Catacomb Culture, approximately 2500-3000 BCE (Before Common Era).

The Catacomb burial of Burial 14 at Budyonnovsk 10 in Burial mound 7. The individual is buried in a crouched position, head orientated south. Image credit: Gresky et al. 2018: 92.

A discreet dysplastic lesion was discovered in the mandible of Burial 14, with the involvement of the right lower canine alveolus.  This was examined via macroscopic analysis, digital microscopy, plain and contrasting radiology, and by thin slicing sections of the mandible itself.  Again a thorough differential diagnoses analysis was carried out and helped rule out Fibrous Dysplasia (monostotic) and Ossifying Fibroma as likely culprits, as Osseous Dysplasia (periapical) suited the physical and microscopic presentation of the lesion.  The important point from this study is that researchers should be aware of the frequent presence of fibro-osseous lesions within archaeological material (Gresky 2018: 97).

The above study initially caught my attention as I have Fibrous Dysplasia (polyostotic), as a part of the rarer McCune Albright Syndrome, and I was keen to see if the osteological literature had identified another individual with Fibrous Dysplasia.  Although this was not the case, it was a particularly interesting read to help differentiate osseous lesions found in skeletal elements within archaeological contexts.

Bibliography

Ablon, J. 2003. Personality and Stereotype in Osteogenesis Imperfecta: Behavioral Phenotype or Response to Life’s Hard Challenges?. American Journal of Medical Genetics. 122A (3): 201-214.

Gresky, J., Kalmykov, A. & Berezina, N. 2018. Benign Fibro-Osseous Lesion of the Mandible in a Middle Bronze Age Skeleton from Southern Russia. International Journal of Palaeopathology. 20: 90-97. (Open Access).

Vairamuthu, T. & Pfeiffer, S. 2018. A Juvenile with Compromised Osteogenesis Provides Insights into Past Hunter-Gather Lives. International Journal of Palaeopathology. 20: 1-9. (Open Access).

A Personal Anthropology of Driving

As I shift the gear stick I can feel the muscles tensing and releasing in my left arm; I can also imagine the tendons moving smoothly under the flesh, like steel lift cables, as the contracting muscles react to the electric jolts shooting down the nervous pathways spread across the body.  Both of my legs work in tandem with my left arm to leverage the accelerator and clutch pedals in a fluid series of movements to change the engines gear, whilst the right arm keeps the steering wheel stable.  

My eyes keep a steady lookout at the road ahead, alert to the changes around me and the weather before me as the grey clouds break and heavy raindrops start to splatter the windscreen.  A quick flick of my index finger switches the front wipers on.  My ears are primed to the sounds of passing engines or the screaming sirens of emergency vehicles.  Perceptibly, but just, I can feel my heart beat that much faster as my right foot presses down on the accelerator.  At a stretch I’d say it was beating in time to the song playing, but that may be poetic licence and an exaggeration…

~~~

Broken Bones: Convoluted as a Medical History

It has been just over  a year since I first started driving in a daily capacity after passing my driving test a few years ago.  It has been a long and somewhat patient journey to get to this stage.  I had passed the theory and practical tests almost two years beforehand, but a well-timed pathological fracture to the right tibia and fibula bones of the lower leg (as, when a tibia breaks, the fibula, acting as a supporting lateral strut to the larger and more robust tibia bone and connected to it by a tough fibrous tissue, also often fractures) kept me off the road for a good while after having just ordered a car for the first time.  After healing from this fracture, the third such transverse fracture for these two bones, I was again ready to hop in the car and onto the road but this time as a fully legitimate legal driver no longer in a training vehicle.  My body, however, had different ideas as I went on instead to fracture the right humerus bone of the upper arm in an accident shortly before receiving the said car, delaying once again my time to drive and the time on the tarmac.

As a direct result of these two separate fracture incidents I gained two new titanium plates as permanent (and palpable) bodily additions and welcomed, though somewhat initially delayed, doses of entinox and morphine to subdue the immediate pain from the fractures themselves.  After the initial throbbing pain of a fractured bone, which is enhanced by the muscle spasms and contractions that often accompany a break of a major limb bone, the pain starts to wear off to a gentle ache once the limb has been stabilized, protected and padded from any further movement or injury.  Where necessary the bone is reduced to the correct alignment.  The reduction of the bone can, without anesthetic, be as painful as initially fracturing the bone itself.  As indicated above my fractures were treated surgically to correct long-standing problems using metallic alloys fashioned into a sturdy plate screwed onto the bone, which help prevent stress shielding and allow the natural responsive dynamics of bone modelling to continue.  It should be stated here that fractures can also be treated conservatively with limb immobilization and pain relief given whilst the bone heals itself, if a good enough reduction and union can be carried out without the need for surgical intervention.

Humerous triptych. Pre-surgical and post-surgical fixation with the use of a permanent titanium plate on the right humerus (upper arm) following the pathological fracture I sustained in an accident in July 2014. As a result of having McCune Albright Syndrome, and the associated Polyostotic Fibrous Dysplasia (PFD) disorder where bone tissue is replaced with a fibrous tissues, my skeletal system is weaker than normal with a higher bone cell turnover rate. Pathological lesions in the bone, which can already be naturally deformed in size and shape, can lead to fractures (so-called ‘ground glass’ visual which can be found on x-rays of PFD bone). If reproduced elsewhere please credit as appropriate and inform the author of this blog.

I said it was a long and patient journey because the majority of the time spent waiting to drive was spent silently healing, my head often buried in an article or a book whilst devouring coffee.  It took a long time for the two pieces of the bone shafts to become one again as the callus formed and bridged the fracture site, the woven bone that is initially laid down changing over time to lamellar, or mature, bone.  So much so that in some cases bone fracture sites can be completely remodeled with little noticeable sign of a historic break ever having taken place.  During this time I was shuttled from appointment to appointment as a passenger in my assigned vehicle, wondering what it was like to dictate the journey and the destination, what it was like to take control.

On Starting

You may think that I would be wary of driving due to the above described frailties that my body imposed on my life, but I was ready to go and ready to face the roads of my country.  I was, and remain, eager to explore the freedom of the road alongside the exploration of the idea that that freedom represents in itself .  Many of my friends had started driving at 17 or 18 years old, had passed their tests and then drove aimlessly to gain experience on the roads around the regional towns, only to abandon their cars as they themselves started undergraduate courses at universities in other towns and other cities across the country.  Running a car, and having the money to fund the fuel bill, insurance, road tax and other associated costs, was an expense that many didn’t have and didn’t need at that time in their lives.

I too had started to learn to drive at that age but I soon gave it up, frustrated at the confusing methods used by the teacher and wary of the upcoming femoral fixation surgeries that I faced at that time to limit what appeared to be regular interruptions of forced stillness in my life.  I was happy to ignore the need to drive for another decade or so, not needing to do it for my undergraduate and postgraduate university courses and happy to use the trains and other methods of public transport for work and pleasure.  Indeed I came to love the numerous hours spent commuting to volunteer placements, work, and journeys to see friends and old companions.  It was time to relax, to speak to other passengers, to sit and to read or simply to sit and to stare at the countyside unfolding before me.

As every driver informs every non-driver, the convenience of the car is the epitome of freedom over the strict timetable of public transport.  As an ardent user and lover of the train (the misery of the delay is trumped by the friends made in the carriage and by the regulars who recognize you in turn), I remained somewhat skeptical of this claim.  What I had not counted on, however, was how it actually felt to have that freedom when I drove myself, both for my own pleasure and as a matter of commuting to and from my workplace.  There have been times when I am driving down an empty flyover at 1am with the twinkle of the industrial north to my right and the disappearance of the work office behind me and, as the song I’m listening to reaches its crescendo, I feel somewhat at peace with the world around me.  This is of course the thrill of riding an empty road listening to your favorite music and soaking in every last note sounded and vocal moaned.  But driving with a crowd is different, but it is different for me in particular.

To Drive, To Think

The car, for me, and the act of driving the car, means that I can merge in with the public body at large in a seemingly innocuous manner.  When I walk I use crutches for short distances and, for longer distances, I need and use a manual wheelchair.  As such it is an obvious difference that is noticed immediately on sight, one which signifies that I am different in some significant way from the majority.  I have had, and continue to have, people treat me differently in ways that they would not my friends or family, say by speaking to someone other than to me even when it is I who have raised the question or query, or by treating me in such a way which invokes past experiences of relatives or loved ones in states of profound impairment, despite the fact that my experiences and needs are different; that is in such cases my personal agency as an actor, or individual, with my own views, worries and questions, is abated.  I am viewed as a representative, therefore I am not an individual.  There is no such differentiation between specialized, or adapted, vehicles for the physically impaired, or disabled, individuals on the road compared with ‘normal’ cars – we all flow into the same lane or road.  (The caveat here is, of course, parking bays where disabled bays, alongside mother and child bays, are given proximity priority but I am strictly talking of when the car is in motion).

As such I am intrigued by the possibility of me in the car being treated in a similar manner as to everyone else who is present on the road.  That our actions speak for themselves, rather than the prejudices present on seeing the physical self as a first judgement.

I’ve briefly touched on my own experiences here and a few ideas above, but I want to move forward to acknowledge a few thoughts that have swirled around my mind over the past year or so on the open road.  I have become somewhat intrigued by the notion of driving, and the path of the road, as a cultural symbol and as a personal experience.  As such the following are thoughts, somewhat vague in nature, of driving.

A Marker By The Side

During the first six months of my experience as a driver I passed a personal marker on the road to work, a curve in the dual carriageway where a silent, single fluttering jersey indicated a geographical spot where a young life had been cut short, the car skidding from the road late at night killing one of its two occupants.  The jersey by the side of the road aptly demonstrated both the family’s singular pain and the danger of driving without due regard for the road conditions, a memento of the often tumult path of life.  It acted as a constant reminder for me then, when I saw it throughout the different seasons of the year, and I remember it clearly now in my mind’s eye.  It is easy to be self-contained in a car if you are driving alone, thinking only of yourself and not of the actions that you yourself have on others and those around you.  That the road is open and easy to see.  Yet drivers, especially of cars, can be subdued too easily by the sheltering in the cage of metal and glass.  Too easy it is to shut out both the weather and the sound of the road, too easy to become disconnected from what is in front, to the side, and behind.  Death is the ultimate outcome of driving dangerously or incorrectly, each person who drives should understand that they are both responsible for themselves, any passengers, and for the safety of those of who the car comes near, be it other vehicle drivers or pedestrians.

A friend who rides a motorcycle near year-round has spoken of their wish that each person who learns to drive does so first on a motorbike, where every second must be concerned, and concentrated with, the movement of your bike and your body, where the dangers in the driving blind spot become that much more pronounced as there is no clear boundary or distinction between the body and the tarmac.  It is an interesting idea, I think, and it shows that although the majority of the road users in most countries are car and truck drivers there are different experiences of using the road out there.  That even though we may be all drivers, we do not each experience the same sense of driving or the same sense of security from the vehicles we choose to use to get from A to B.  It is my suggestion that this is the experience of the other in this environment, the one that car and truck drivers must take extra special care for motorcyclists (as well as cyclists) due to the physical differences in the size of the vehicle and the position of the body on top of the vehicle, rather than the notion of what it feels like to be on the inside of it.

Thoughts on Interior vs Exterior

However, within the confines of my personal anthropology of driving, there is also a need to define the personal space within the interior of the car and the exterior public face of the vehicle, i.e. the personalization of the interior as a representation of the identity versus the need to drive responsibly and react accordingly to the changes in weather, traffic density and normal, or exceptional, road hazards.

We have all, for instance, seen the personalized number plates or stickers attached to the exterior surface of cars, or the use of rosary beads dangling from the rear view mirror, possibly signifying a religious connection to Catholicism or perhaps simply a physical item in which to grab and to hold, to reassure and to connect.  These are markers of expressed individual and group identity through the modified material culture of the car, which could be symbolic of the beliefs of the individual and, possibly, an indicator of the nature of their personality, although there must also be a distinction between these leaps and not infer beyond the unreasonable.  These do of course differ dependent on the circumstances.  The cliché of a boy impressing a girl by driving fast is indicative of the use of the vehicle to express dominance or perceived masculinity and not the expression of the material culture of the individual within the car.  There are, as such, different signifiers at work when we consider the expression of identity with regards to vehicle ownership and use (see photograph below).

‘Warning: if you value your life as much as I value this truck don’t mess with it!’. Seen in San Francisco in April 2015. Photograph, taken with a digital camera, by the author. If used elsewhere please credit as appropriate.

So what is in my car?  You can expect to find the odd physio stretching band, placed in the car from before I started to drive so I could exercise the muscles of the right arm on the way to and from work, to regain the majority of the extension of the antebrachium back.  (I have permanently lost the ability to fully extend my arm due to the somewhat intimidating and unnerving bend of the right humerus – it isn’t immediately noticeable, the bend, but when I point it out in person you may be surprised and somewhat horrified at what once was and now what is).  Look into the main storage box and you’ll find a whole heap of CD’s covering a fairly wide range of genres and musical styles, from the cut and thrust of Fugazi and their 13 Songs album to the emotional tape loops of Steve Reichs Different Trains and Guitar Counterpoint.  You could probably tell that the CD medium is the one in which I invest the most in for music listening just via the car haul of discs themselves.  I’m forever rotating my classic selection of favoured albums that I’ve purchased more recently, such as Joanna Newsom’s Divers, the Godspeed You! Black Emperor album Asunder, Sweet and Other Distress, or Sufjan Steven’s hauntingly beautiful Carrie and Lowell album.  The car, now, has become one of my prime personal music venues, enhanced by the visuals on the road and the acuity of speaker-to-body distance.  The drive to and from work allows for the almost total immersion of sound to radiate around me, to envelope the body and invigorate the mind as I drive.

The expression of music is carried on in the material contents of the car by three or four worn drumsticks perched precariously in the front chair’s backseat pocket.  The drum sticks head and necks are pretty worn away, indicative of their active life beating the various tom toms, snares, and high hats of drum kits across the rehearsal and practice rooms of my home town.  If you dig a bit deeper it is quite possible you may find a roll of film (now I’m really harking back to pre-digital technology!), indicative of the ownership of my beloved cheap Pentax camera, which sometimes finds a temporary home in the car for when I am out and about; it is sometimes paired with my cheaper-still digital camera.  Nestled in the front passenger seat is a battered copy of Will Self’s experimental novel Shark, a copy of which I convince myself I will finish one day.  (Regardless of the growing stack of novels and non-fiction books that mount beside my bed.  Karl Ove Knausgård’s Min Kamp circle of books has taken my recent fancy as well as Janine Di Giovanni‘s more somber documentation of Syria’s ongoing destruction in her book The Morning They Came For Us: Dispatches from Syria).  It is, I think, also an expression of the need to read in down times, where I find myself waiting for one reason or another.

So these are the two big things you may notice in my car – music and books, but what does the car and the road say about us from a non-individual status?  What laws do we follow and why, what are the roads laid out before us and why do we subscribe to a set of nationally, and internationally, prescribed laws?

State Expression

As such it could be highlighted here that the need to observe the rules of the road are, essentially, laid in law by whichever, or whoever, is in control of the land itself.  That is, the road, and the population who drive on that road, are obeying the rules in a manner prescribed by the ruling power and as such act in that way.  This could be a potentially reductionist approach to understanding how countries or cultures approach driving and the road network, however it is also an intriguing area of interest.  Allow me to expound briefly on the above point.  The expression of the state is manifested by the obligation of the driver to obey the rule of the law on the road, whilst the interior environment of the car allows for a personal reflection of the identity via its material culture.  Aligned to this are group identities expressed in this way – they can be cultural, religious, personal, or idiosyncratic in nature.  We’ll take a very quick global tour to explore some of this expressions of individuality within group expression.  I’ll also highlight some of the cultural restrictions placed on car drivers in different countries as it can be easy to think that each country’s laws are similar to one another, but cultural restrictions play an important part in this as a projection of the country’s laws and beliefs.

Road Changes & Cultural Restrictions

Road space rationing is the term used to describe the strategy to limit road users using particular methods of restriction.  These can include methods such as no-drive days, alternate day travel, and general restrictions on road access.  The strategies are used globally as temporary or permanent measures to decrease vehicle use and environmental impact, largely in major cities but also with increasing use in major industrial countries such as China and India.  A similar method to this is the use of car-sharing lanes where privileged road, or lane, access is given to cars containing more than one person as an incentive to cut single person travelling.

In London, England, the permanent Congestion Charge Zone was introduced in 2003 to combat the growing number of vehicles entering the center of the capital city, as a means of cutting down environmental damage and of limiting the sheer volume of traffic.  Bikes, and notorious Boris Bikes, have been particularly targeted as the green and safe way to travel within the city center alongside the extensive public transportation routes.  Transport for London (TfL) have stated that there has been a 10% reduction in vehicle traffic in the decade since the introduction of the congestion charge, which has found favor with a number of residents of the city.  In the capital of France, Paris, a temporary scheme whereby owners of cars with odd or even number plates were not allowed into the city on that particular day or days was in place during a particularly polluted period in 2014.  Temporary measures such as this are largely aimed at immediately cutting smog that threatens, or has, blanketed the city in question.

Other methods include closing down particular routes or roads during particular days.  In São Paulo, Brasil’s biggest city, a normally packed 3.5 km section of the Minhocão highway (nicknamed ‘the Big Worm’) is returned for the use of pedestrians and cyclists only each weekday evening, Saturday afternoons and full Sundays during the summer period.  Whilst Minhocão has been partially closed to vehicles for 26 years, there has been a new movement to close down Avenida Paulista in the city on Sundays as well.  The schemes in São Paulo is used as an urban reclamation of roads, or transportation routes, as a matter to regain urban walkways and increase the use of public transportation and finds similarities with a number of schemes across the globe.  For instance in New York City, USA, the reclamation of the 1.45 km long High Line, an old railroad renovated as an elevated walkway festooned with shrubbery, has seen it become a major attraction within the city itself in its own right.

The car can become symbolic as in this case where it is the icon of a city forever on the move. The New York taxi is one such symbol and if encountered on its home turf is often accompanied by an incessant honking of the horn and the permanent background noise of a thousand ticking engines running over, forever stopping and starting. Photograph, on a digital camera, by the author. If used elsewhere please credit the author as appropriate.

New York City is both famous and infamous for its classic yellow cabs that litter the city.  To any driver from Europe, the roads of American cities can present a challenge as American cities are often built on the grid pattern, much like the ‘new city’ of Milton Keynes in the United Kingdom.  In such a busy and compacted city as New York this invariably means that the traffic never truly gets a chance to flow due to the traffic lights at each and every corner dictating who goes where when.  On a visit to the city that I was lucky enough to have last year I couldn’t help but notice the truly gigantic sounding board that the multi-storied buildings of Manhattan presented as the taxi drivers and drivers throughout the city incessantly honked their horn.  It surprised me, but also moved me in a way I had not expected – I was in the city of the movies, arguably the heart of the country itself in all of its architectural splendor and Freudian intimidation alongside the metaphorical American Dream representations.

As I come to the conclusion of this post I have presented a quick introduction to some of my thoughts, rounding down to international approaches to do with the increase in the number of the drivers and the damage wrought by diesel and petrol hungry engines in city centers, not to mention the natural environment.  Yet there is much more that I feel I ought to write, I haven’t touched on the interesting subculture of young male drivers in the kingdom of Saudi Arabia in which steam is let off by drifting (or Tafheet) and other associated vehicular activities, not the mention the incredibly strict restrictions placed on females in the country (females are forbidden from driving, although this is not illegal per se, it is heavily policed with punishments handed out for females caught driving).  Nor have I mentioned the fascinating subculture of bōsōzoku in Japan, which centers around the customization of cars and motorcycles.

The post describing these subcultures can perhaps wait for another day as this post has reached a fairly substantial length already.

Disengaging the Engine

So those are my brief thoughts on a personal anthropology of driving with a few nods to international views and explorations.  Nothing substantial, just a brief overlay of ideas that percolate through my brain as I slip on my seat belt, engage the engine and accelerate away onto the tarmac before me and into the night ahead of me.

Influences & Further Reading

BBC & British Library Sound Archive. 2015. Noise: A Human History. An Ever Noisier World. Episode 29 of 30. BBC Radio 4.

Martin, D. L., Harrod, R. P. & Pérez, V. R. 2014. Bioarchaeology: An Integrated Approach to Working with Human Remains. New York: Springer.

Robb, P. 2005. A Death In Brazil: A Book of Omissions. London: Bloomsbury Publishing.

Humerus Triptych: Fracturing & Fixing

I just can’t seem to help myself.  No sooner do I find out that I’d previously (and unknowingly) fractured a number of my ribs over a period of years, do I go and fracture my right humerus in the early evening sun of a peaceful July night.  It was, of course, shortly accompanied by the familiar wash of painkillers that helped numb the pain somewhat.  I’ve mentioned the humerus fracture a number of times in recent blog entries but I have not, until now, managed to obtain copies of the X-rays to highlight the break itself, and the subsequent surgical procedure that I underwent to fixate it.  With thanks to modern technology, I present to you below my right humerus in post-accident pre-surgery and post-accident post-surgery poses, if you will.  As White and Folkens (2005: 312) highlight fractures normally occur ‘as a result of abnormal forces of tension, compression, torsion, bending, or shear applied to the bone’, and they are often described by the features of the break itself (i.e. transverse, oblique, spiral etc).

I have long feared fracturing any of my bones in either upper arms (brachium), forearms (antebrachium) or hands (manus), even though I’ve had a somewhat turbulent history of pathologically fractured bones in my lower limbs.  Alongside this I have also undergone a fairly extensive list of elective surgery to fixate the femora and right tibia due to the effects of McCune Albright Syndrome (including improving the angle of the so-called shepherd’s crook deformity of the femoral neck).  Thus where a natural fracture or planned surgical procedure on the lower limbs may mean I cannot use my crutches for a few months, I can still use the wheelchair to maintain physical independence.  This is not so with a fractured upper limb, where healing will take many months.

To return to the common name usage, I rely on my arms not just for holding or grasping objects but for the locomotion of my manual wheelchair.  As such they are my legs for daily mobility.  I use them also to partially bear my weight when I use my crutches to walk, so a fractured upper limb bone would mean walking is out of the question as well.  I have fractured a humerus only once before, aged 13 at school.  An ill-advised arm wrestle resulted in my friend looking at my pale and quickly draining face in horror as I cradled my snapped right humerus in shock.  It is safe to say that my friend won that match, and I’ve been wary of competing in arm wrestles ever since!  The result of that match was a lengthy spell in plaster (or some variation thereof as, after few months, plaster gave way to support splint, and splint gave way to a laughable plastic guard).

X-ray of my brachium (upper arm) with the transverse (possibly oblique) fracture of the right distal humerus in a cast before surgery (far left), the post-surgery fixation with a titanium plate and screws (centre), and finally a view of the brachium that highlights the plate and the depth of the screws (right), which help to keep the fixation and fracture site stable by equally distributing stress.  The tell-tale signs of the ‘ground glass’ appearance of polyostotic fibrous dysplasia (as a part of the McCune Albright Syndrome that I have) can also be seen in the X-rays, as can the evidence of a previous fracture and natural bowed shape of the humerus.

In truth the recent humeral fracture was the result of my impatience, gained as a result of quickly bouncing off a curb to catch a waiting taxi, and coming off worse for wear as the wheelchair tipped and I instinctively shot out my right arm to stop myself.  The pain from a fracture comes not from the bone breaking but from the damage to the soft tissues that surround the bone.  The periosteum, a tough connective tissue that nourishes and covers all outer external surfaces of the bones barring articular surfaces of the long bones, is home to nerves that the bones themselves are not (White & Folkens 2005: 42).  A fracture of the bone often damages the periosteum tissues (which causes pain) and leads to swelling of local tissues.  The periosteum, and associated endosteum membrane (located on the inner surface of bones), are also one of the origins where the precursor bone cells develop into chondroblasts and osteoblasts, which are essential for helping the bone fracture heal successfully (White & Folkens 2005: 43).

A small but significant benefit of having polyostotic Fibrous Dysplasia is the fact that the pathological fracture patterns tend to be transverse breaks due to the weak structure of the bone architecture, which tends to limit injury to both the nerves and the soft tissues surrounding the fracture area (Marsland & Kapoor 2008: 121).  However, due to the pathological bone porosity and the often high bone cell turnover rate as a part of the overall syndrome, there is the prospect of extensive bleeding during surgical procedures.  This can lead to extensive blood loss during major operations (such as during osteotomy procedures and/or internal and external fixations to help improve the bowing of a limb or to correct pathological fractures).  As such the patient’s blood is often cross matched beforehand with suitable blood groups, for infusion during major surgical procedures to combat excessive blood loss.

In the immediate aftermath of the fracture I was given heavy painkillers and taken to hospital where, after a light sleep overnight, my arm was put into a cast before I underwent surgery later in the week in a hospital nearer my hometown.  The decision was taken not to reduce the bone before the surgery and just to rest it.  On weight bearing bones (such as the tibia or femur) or load bearing bones (such as the mandible in adults), it is important that the bone is reduced quickly and properly to minimise complications and induce good healing (Marsland & Kapoor 2008: 120).  The humeral fracture was openly reduced and fixated under general anesthetic with a titanium locking plate, as can be seen in the above X-ray, and the surgeon achieved a good fix and stability of the distal humerus with the plate.

Curiously, even though the fracture was trauma induced, it was less painful than the fracture that had occurred when I was 13.  The arm still feels heavy and slightly cumbersome, but there is no doubt that the internal fixation is preferable to the months in the plaster cast.  It will still take many months for the bone to heal properly as it is still in the early stages of the primary bony callus, a process where woven bone bridges the initial fibrous connective tissue callus that responds to a fracture in the first few days.  This woven bone is, after a few months, later converted to lamellar bone and the fracture site will be further remodelled.  Eventually, if a fracture site is initially kept stable by immobilization or by fixation as in my case, the bone can remodel so completely as to eliminate any trace of the original fracture (White & Folkens 2005: 48).

Traumatic fractures are found in all periods of human and hominin history, and it is likely that you yourself have suffered a fractured bone of some description, perhaps even unknowingly (Marsland & Kapoor 2008: 121).  They can be devastating, requiring many years of surgery or physiotherapy to gain and improve movement as the sociologist Ann Oakley highlights in her 2007 book Fracture: Adventures of  Broken Body, a personal account detailing the social and professional impact of a fractured right humerus accident which had impinged on nerves, leading to reduced function and feeling.  Fracture treatment has been practiced for thousands of years and it has long been known that, with the reduction of the break and stabilization of the limb, good results can be achieved (Marsland & Kapoor 2008).  The study of fractures in populations can also highlight trends in the attention received as Meyers (2012) has highlighted in an entry on the differences of fracture treatment between Iron Age and Romano-British populations in Britain.

The right tibia of an adult, courtesy of the free online resource Digitised Diseases. Notice the well healed mid-shaft oblique fracture in the (a) anterior view, (b) is the posterior view and (c) is the close up posterior view, where right is proximal and left distal. The callus is fully remodelled with smooth bone over the fracture site, where the end is displaced laterally and proximally. Image credit: Digitised Diseases 2014 (Master Record Number 0365).

Still this entry’s approach is focused on the personal, not at the population level.  Another part of my body has broken and it is once again held together by titanium, likely to be a permanent addition to my skeleton.  The movement at the glenohumeral joint (otherwise known as the shoulder) is normal while movement at the elbow joint (comprised of the humeroulnar, humeroradial and superior radioulnar joints) is almost back to normal.  There is still a lack of full extension of the joint, with noticed tension in the biceps brachii muscle as it acts as the antagonist to the triceps brachii muscle during forearm extension, although daily physiotherapy should help to regain full movement.  I am no stranger to the strength of the metal in my body and I remain impressed by its capability in the use of orthopaedic fixation.  The use of metallic implants to fixate fractures is nothing new as Lane (1895) and Uhthoff et al. (2006) attest.  Whilst the use of casts to set fractures continues, it is the increase in the use and versatility of technology and materials to give nature a helping hand that remains the next big step in treating bone fractures (Bali et al. 2013).

Metal plates have been in use for over a hundred years where early pioneers such as Lane (1895), Lambotte (1909) and Sherman (1912) first introduced plates to help stabilize fracture sites and help mobilize patients faster than plaster casts could allow (Uhthoff et al. 2006: 118).  Although these early plates suffered from corrosion problems it soon became apparent that internal plate fixation could provide a safe and efficient way for patients to heal, whilst also regaining some form of movement.  Various plate designs improved on earlier designs, allowing for micromotion at the fracture site and compensation for bone resorption during the healing process.

Uhthoff et al. (2006: 124) contend that there are still problems in the form of internal plates, where compression and stress shielding can still lead to bone necrosis and cortical porosis.  In their conclusion they argue that there still needs to be a fine balance attained between a plate design that managed to reduce stress shielding and allows adequate micromotion at the site of a fracture, both which they concur would help mimic biological healing.  There also drawbacks that can include plate palpability, risk of infection, temperature sensitivity and possible growth restriction with metallic implants (Bali et al. 2013: 167).   Ultimately however the body still has to heal the fracture itself over a matter of weeks and months (White & Folkens 2005: 48).

It is interesting to note that Sir William Lane himself, writing in the late 19th century and primarily focusing on lower limb fractures, indicates the marked differences between upper and lower limb fracture treatment.  He states that although the upper limb does not take the weight of the body:

“… in the arm very considerable alterations may occasionally develop, and are more marked and depreciating to the value of the individual as a machine in proportion as changes have already taken place in the particular joint or joints from the prolonged pursuit of a laborious occupation.” (Lane 1895: 861).

Deciding that fractures of upper limb need not be set directly in their original anatomical form, whereas lower limb bones should be set as close to as originally constituted due to their weight-bearing nature.  Furthering this view, in the same letter to the British Medical Journal in 1895, he highlights that:

“One cannot but feel that the perpetuation of methods of treatment which have been in use up to the present time must depend on the fact that surgeons have not taken such trouble to inquire into the subsequent life-history of these patients as they have done in other departments of surgery.” (Lane 1895: 863).

There have been some distinct advances in using biodegradable plates in non-weight bearing locations, such as in the maxillofacial region, a position where many would like to avoid the intrusive nature of a temporary or permanent metal plate.  A study by Bali et al. (2013: 167) has highlighted the value of using biodegradable material to help fixate trauma-induced facial fractures, reporting that each individual in the small study cohort (N=10) of varying ages, reported good reduction of fracture and evidence for the total biodegradation of the plate after two years.

They also reported that no further surgical procedures were needed on their test cohort, a significant finding as metallic implants often either need removing if they are temporary or debriding if they become infected, both quite serious surgical procedures (Bali et al. 2013: 170).  Unfortunately the study highlights that biodegradable implants are unlikely to be currently safe to use in weight-bearing or load bearing bones.  Bali et al. (2013:171) conclude by stating that further studies are needed but biodegradable plates and screws can provide satisfactory, if expensive, stabilization as internal fixations for mid-face fractures.

Medical science and engineering has certainly come a long way since Lane first introduced the internal fixation plate, yet humans are as prone as ever to fracturing their bones.  As a person with McCune Albright Syndrome I may know the pain of breaking a bone, but I can be thankful that I live at a time and in a place where fractures can be confidently treated.

Further Information

• I’ve written in more detail on polyostotic Fibrous Dysplasia and McCune Albright Syndrome here, which details the way in the which the disease has affected my skeleton.  Also, on that particular post, are a host of medical, palaeopathology and osteology related articles to do with McCune Albright Syndrome and Fibrous Dysplasia in general.  Alternatively search the blog for the keywords and numerous posts in which I’ve highlighted the syndrome and the bone disease will appear.

• A previous post on 3D printing in orthopaedic surgery can be found here, and an entry giving a quick overview of some of the problems and approaches used in studying physical impairment and disability in archaeological contexts can be found here.

Bibliography

Bali, R. K., Sharma, P., Jindal, S. & Gaba, S. 2013. To Evaluate the Efficacy of Biodegradable Plating System for Fixation of Maxillofacial Fractures: A Prospective Study. National Journal of Maxillofacial Surgery. 4 (2): 167-172. (Open Access).

Digitised Diseases. 2014. Master Record Number 0365. Accessed 18/08/14. http://www.digitiseddiseases.org/viewer/viewer_overlay.php?MRN=0365#.

Lane, W. A. 1895.  Some Remarks on the Treatment of Fractures. British Medical Journal. 1 (1790): 861–863. (Open Access).

Marsland, D. & Kapoor, S. 2008. Rheumatology and Orthopaedics: Crash Course 2nd Edition. London: Mosby Elsevier.

Meyers, K. 2012. Break a Leg! Fracture Treatment in Iron Age and Roman Britain. Bones Don’t Lie. Accessed 11th August 2014. (Open Access).

Oakley, A. 2007. Fracture: Adventures Of A Broken Body. Bristol: Policy Press.

Uhthoff, H. K., Poitras, P. & Backmann, D. S. 2006. Internal Plate Fixation of Fractures: Short History and Recent Developments. Journal of Orthopaedic Science. 11 (2): 118-126.  (Open Access).

White, T. D. & Folkens, P. 2005. The Human Bone Manual. London: Elsevier Academic Press.

Pain, Briefly

Just a quick note here.  I had the good luck of hearing historian Joanna Bourke on BBC Radio 4 program Start the Week yesterday morning who was on the show debating the topic of her latest publication titled, The Story of Pain: From Prayer to Painkillers.  The book focuses on trying to understand and contextualise the feeling of bodily and physical pain from the 18th century AD to the modern period.  Bourke, who is a Professor of History at Birkbeck, University of London, presents a holistic history of understanding pain in which the topic is approached from numerous angles, including not just the medical but also the cultural, religious and political.  The book also deals with the personal experience of pain and the nature of suffering, both in the individual sense and within wider society from the family out.  It certainly looks like an interesting and enlightening read.

Having read a few reviews of the book itself, and of having heard Bourke herself discuss the differences in understanding the many types of pain, it reminded of sociologists Ann Oakley’s 2007 book Fracture , of which I discussed a little here.  Although Oakley’s book is a much more personal and reflective study with its focus on the modern health perspective, Bourke (2014) also discusses the role and changes that medicine has gone through in the past and present approaches and treatments when considering illnesses and patients themselves.  Of particular interest on the radio show this morning was Bourke’s assertion that different cultures experience pain in a myriad of ways.  This, of course, made me think of how bioarchaeologists approach the archaeological record and how we try to understand palaeopathology in relation to the individual osteobiographic context, within the population and society that the person lived in, together the original context of the landscape environment of the archaeology site (read more about osteobiographical examples here).

Bioarchaeology is, as a field, a burgeoning area of archaeological research, one that ably and actively straddles the humanities and science divide with ease.  Bioarchaeologists often complement their normal macro and micro assessment of the skeletal remains with the regular use of the latest scientific techniques and refinements, including but not limited to stable isotopic and ancient DNA analysis, to help understand the processes, implications and contexts of a pathology within a population.   This often includes trying to contextualise and understand traumatic or congenital pathologies that can be present in the skeletal remains of humans (White & Folkens 2005).  It must be remembered of course that only a small fraction of diseases known ever affect or actively present on bone itself (Waldron 2009).

Pain though is rarely considered when describing a pathology that is present on an archaeological bone.  This is partly due to the nature of the limitations of archaeology, but also partly due to the existing bioarchaeological literature.  Care to not exceed the evidence must take precedence, otherwise bioarchaeologists risk inflating the boundaries between the known and the unknown.  Pain itself is a uniquely personal feeling and it can be a difficult feeling to describe.  It can also be paradoxical as to know pain is to be reminded that you are alive, but to know that pain means it is also a warning that life is threatened.

As a purely personal perspective I have recently found out something rather interesting about my own skeletal biology.  As readers of this blog may be aware that I have McCune-Albright Syndrome (MAS) and, as a part of this, polyostotic fibrous dysplasia.  MAS is, as far as it is currently possible to tell, a fairly rare bone disease that can lead to fractures and bowing of the bones (more information here and also Dumetriscu & Collins 2008) amongst other things.  Having broken a good number of the long bones of my body, I am now acutely aware of what a fracture feels like.  Recently however, and completely unbeknownst to myself beforehand, I learnt that I have been fracturing my ribs for a number of years, as both x-rays and a CT scan showed a fair amount of bone re-modelling and faint healed fracture lines on a number of ribs.

Why hadn’t I noticed?

Partly it was because the fractures themselves weren’t that painful (I am well aware that rib fractures are usually pretty painful).  In fact I have been aware for years that I occasionally pull the superficial or intercostal rib muscles on either side periodically, and that this had always led to a good few days of unease if I slept on the affected side, coughed or laughed too hard.  I had put this down to using the wheelchair more over an extended period of time starting from my mid adolescence, following on from several major surgeries on the femora.  I reasoned that due to repetitive nature of the motion of wheeling in a manual wheelchair the muscles were bound to get sore and fatigued at some points.

A copy of the posterior to anterior x-ray of my own chest. Although the healed rib bruises and fractures cannot clearly be seen on it, the constriction of the chest wall is highlighted (black arrows).  This can have an effect on the air intake of the lung capacity.  Generally fractured ribs are left to heal naturally unless there has been puncturing of internal organs by the ribs themselves, in which cases surgery is needed.  (Read more here).

I was well aware that the ribs are one of the more common areas of the body to be affected by MAS, along with the femora and cranial bones, yet I paid little attention to what I thought was a pulled muscle  (Dumetriscu & Collins 2008, Waldron 2009).  I could still move relatively fine afterwards, and it certainly wasn’t that painful.  So, as you can imagine, I was somewhat surprised to hear that I had at least four previous rib fractures that had healed, which were clearly evident on the X-rays and the scans taken of my chest as I saw.  I should state though that it is likely to have been a mix of micro, hairline and full fractures on pathologically diseased bone, and not traumatically induced fractures which, I hear, can be extremely painful.

As such, and having heard Bourke talk about how individuals cope with pain, it should be taken into account by bioarchaeologists that skeletal pathology probably elicited different responses dependent on the social and cultural context of the individual.  This is of course important when considering the impact of a pathology present on the bones.  This, necessarily, becomes more problematic as we reach further into history and prehistory, where the lack of contextual and written evidence can be missing or non-existent.

However, as archaeologist and bioarchaeologists, we must also continually ask questions regardless and especially when skeletal material has already been analysed.  New techniques, theories or methodologies are only useful once they have been applied to the existing archaeological record and are repeatedly tested against what we think we know.

Alongside Bourke on the Radio 4 show was the current director of the Wellcome Trust, Jeremy Farrar, who discussed his experiences as a medical doctor and the possible implications of the overuse antibiotics, and Norman Fowler, a conservative MP who oversaw the public health campaign against the spread and threat of HIV/AIDS in the 1980’s in Britain.  Each guest on the program was well worth a listen.

It is safe to say that Bourke’s work is another book that I shall be adding to my ever increasing pile.

Further Information

• Listen to the Start the Week program, on which Professor Bourke appeared, on BBC Radio 4 here.

• A review by The Guardian of the History of Pain: From Prayers to Painkillers book be found here.

Bibliography

Bourke, J. 2014. The History of Pain: From Prayer to Painkillers. Oxford: Oxford University Press.

Dumitrescu, C. E. & Collins, M. T.  2008.  Overview: McCune-Albright Syndrome. Orphanet Journal of Rare Disease. 3 (12): 1-12. (Open Access).

Oakley, A. 2007. Fracture: Adventures Of A Broken Body. Bristol: Policy Press.

Waldron, T. 2009. Palaeopathology (Cambridge Manuals in Archaeology). Cambridge: Cambridge University Press.

White, T. D. & Folkens, P. 2005. The Human Bone Manual. London: Elsevier Academic Press.

Future Steps?

I have recently had surgery on my lower right leg following the transverse fracture of the tibia and fibula a few months ago, so I haven’t posted for a while.  The surgery, in which osteotomies were performed on the tibia and fibula to re-align the bones and re-distribute the weight along with having the tibia internally fixated with a locking plate and screws, was quite successful thankfully (x-rays to come if I can get my hands on one, quite looking forward to seeing the new hardware for the first time!).  It also gave me some more time to ruminate on the meaning of this blog: of the blog’s form, function and interactivity.  The basic thinking behind the site remains, as per my established aim, for it to become a repository for both my own continual learning and to provide a place for a wide audience to learn about human osteology, specifically the role human osteology plays within archaeology.

An example of a high tibial osteotomy near the knee to improve the angle of weigh-bearing and biomechanical properties of the leg: where (a) represents the presenting angle, (b) the surgery to access the joint and (C) highlights the wedge of bone removed in the osteotomy procedure and finally (d) the corrected angle post-surgery.  In my case the distal tibia and fibula were surgically fractured and osteotomies carried out on the medial aspect of both bones to improve the biomechanical loading of the lower limb with internal fixation applied to improve strength (Source: SOTRS).

Development Of A Medium

This blog has developed naturally over the two and a half years since its inception to include what I like to think of as a ‘three-pronged’ approach:

Firstly, the development of the Skeletal Series to introduce the individual aspects of a human skeletal to a general audience.  This is ongoing and has proved relatively successful I think, with some lovely feedback from both members of the academic and public spheres.

Secondly, the ongoing Guest Posts in which various organisations and individuals have agreed to write an informed blog entry on their specific area of knowledge or interest.  This has been a  particularly fruitful approach in widening the topics of discussion on this blog.  This has also led to the development of the first interview on the site, of which I am particularly happy as it has allowed the elucidation of a new methodology in a clear and straightforward manner.  I am hoping that these interviews will become a much a feature of the blog as the guest posts have, and it is something I shall try to develop on the site.

Thirdly, general posts by myself on a wide variety of topics that perk my interest.  Within this I have included posts on specific articles, brief book reviews and personal posts.  The personal posts often discuss the effects of a bone disease little mentioned in the public sphere helping I hope, in a small part, to raise the profile of McCune Albright Syndrome.  As a person with McCune Albright Syndrome, and its component bone disease Fibrous Dysplasia, I have found little online in the form of information from other individual’s with the same syndrome, as such I hope my efforts in describing what I have been through, and what I continue to go through, remains useful in providing information on the syndrome and in providing a personal perspective.

Further to this the site also has numerous links to many resources including links dedicated to researchers, journals and other blogs.  These links are located in the categories side bar (referring to categories discussed in my blog posts), and the blog roll (links to external sites) which can be found underneath the body of the posts.  I hope these provide further in-depth information for the dedicated learner and explorer.

Whilst I am deeply happy that this ‘three-pronged’ approach has developed organically, I cannot help but think of the future of the blog.  I do not post as often as a should, nor as often as I want, but I post because I want to, the pressure to actually post being purely self-contained so to speak.  As such there may be periods where this blog is silent, but that does not mean that it has ceased to function.  Indeed I often wonder how many hours of work have actually gone into producing this blog, as it can be quite time intensive to source, write and produce the blog posts themselves.

There are remarkably few dedicated and consistently updated bioarchaeology/human osteology related blogs on the internet (there is a whole delicious raft of archaeology blogs however) and, whilst my site is certainly one of them, the other two are fairly well-known and well-regarded blogs.  Kristina Killgrove, the bioarchaeologist behind Powered By Osteons, has stated that she sees her site as an open lab book where her own research is presented in detail to the public.  Her site is regularly features posts on popular presentations of human osteology in the public domain, as well as updates on themes and articles in bioarchaeology (particularly Roman bioarchaeology).  Katy Meyers, a doctoral researcher who blogs at Bones Don’t Lie, regularly writes about the main topics in bioarchaeology including posts on mortuary approaches and reviews of academic articles (articles often not available to the public).

In sum Katy’s blog helpfully introduces a wide audience to the many facets of what it is bioarchaeologists actually study and why.  Katy is also arguing that her site should be taken and perceived ‘as a scholarly publication’, which would be recognised and credited as a function of her research, in particular as a dedicated source and evidence of her public engagement.

What Does It Mean?

Having mulled over many a thought in relation to open access, public outreach and viewing blogs as scholarly publications, I have thought and developed several ideas in my relation to my own creation.  Could I argue that this site is a scholarly publication?  Whilst I try hard to reference scientific articles as and when possible, particularly open access articles, I am overtly aware that my site is purely written, edited and overseen by me alone.  There is no peer review process, no-one looking over my shoulder for factual mistakes, scientific faux-pas or grammar mishaps.  A blog is a fluid, dynamic interface which, by its very nature, can be changed, edited or deleted in an instant.  They are, essentially ephemeral in tone, having no physical basis in reality (the average blog lasts for just 3 years).  Not that this last point mitigates the content of a blog just it’s possible permanence.

As highlighted in a previous entry there are plenty of scrupulous ‘journals’ out there, willing to discredit real research and plagiarise hard-working researchers, but there are also blogs which are peer-reviewed and monitored for content.  A key counterpoint is to remember that blogs can have a real immediate impact on an audience’s  understanding of a topic.  The nature of a blog is that it is fast fast fast: posts can be produced rapidly and posted online extremely quickly, reaching an international audience within minutes.  This is their inherent value, that research that has been carried out can be produced rapidly to an interested or already developed audience, as well as reaching new people continually.  On a personal level I am astounded and honoured to be mentioned in a few academic articles as a resource for human osteology/bioarchaeology online and for the value of the content of this blog (see previous posts).  It is, of course, wonderful to be acknowledged and recognised in such a way, particularly by your peers and established academic researchers.

I try to edit older posts for content and spelling/grammar mistakes, update posts detailing ongoing research programs or news items and new scientific methods or evidence (I often cringe when re-reading the earlier blog entries!)*.  Of course I also maintain control over what is exhibited and shown on the site itself.  Friends have suggested that I move the site and place advertisements to gain a small stream of revenue from the internet traffic.  I have always resisted this line of thought as I want the blog to be educational and free, without any pressure to buy a book or click on adverts.  Wordpress, necessarily, add a single advert into posts when they are viewed alone but these are largely unobtrusive to the reader.  My view may change in the future, if I decide to host the site myself or pay WordPress to upgrade the site, but ethically it does not bode well for me to place adverts over a site such as this, especially if I am espousing the spread of free education.

On a personal level this blog is my main interaction with academia now that I have finished my Masters degree, as it allows me to engage with a wide and disparate international audience, to dream up collaborations, ideas and possible research projects.  So far however I have not mentioned any original research on this site conducted by myself (minus my MSc thesis abstract).  Although this is something I hope to change within a relatively short time, it can feel as if this blog could (and sometimes does) become an eternal feedback loop (co-incidentally there is a fantastic blog post here, by Benjamin Studebaker, that discusses echo chambers in journalism and blogs).  Interactivity on the site has been mostly conducted via personal email or over Facebook, and I admit I have been slow to advertise the site itself on any other social media platform.  It is only recently that I have installed the ‘social media’ advertisement buttons on the blog site itself; I have yet to make a personalised Twitter or Facebook handle for the blog (frankly this is something I am loath to do).  In a way I want the site to stand alone, on its own merits as such.  This may be foolhardy, especially in the sense that I want this blog to help educate a general and interested audience, but it is also perhaps just a factor in my own beliefs regarding the use of social media.

Future Steps

So what are the future steps for this blog?  The social buttons that are now an integral part of the posts, which also feature email and print buttons, are ready for the sharing.  I am pretty keen that information on this site should be shared if possible.  There are issues regarding the printing of separate blog entries from this site as it is likely that copyright issues, with regards to the images specifically, would be a problem (I would expect the use of Creative Commons attribution attribution share alike licence to apply for any use of the written material on this site).  Is there a way around the copyright image issue?  The image below highlights what the printed pages would hopefully look like in physical form.

What the option to print the skeletal series looks like, with the example of the human spine entry. Note that the hyperlinks in the body of the text present as full website addresses in the text itself when printing the entries on paper. The copyright of the image would also be a problem.

So what can I do to mitigate this problem?  I could make the posts unavailable to print, but that would make the rest of the post inaccessible to print.  I could remove the images from the posts themselves and produce my own diagrams, but at this current period in time I do not have the photographs or drawings necessary to illustrate the posts.  What I have thought of is to go through each of the skeletal posts again, edit and add to them and produce a cheap ebook to sell online, a kind of basic introduction to the human skeletal system and its range of applications in human osteology.  The writing would be somewhat clearer and more concise, and I have thought about the illustrations as well and where they could possibly originate from.  At the moment this is a possible pipe dream, but one in which I have been ruminating on as a natural extension of the skeletal series posts when they have been completed eventually.  The posts themselves will remain up and free, as this is one of the main aims of this site.  I am a firm believer in giving the audience options where possible on how they should invest or use social media, so would you, as a reader of this blog, be interested in such a product? (I’ll need to do market research beforehand of course!).

Returning back to the eternal feedback loop comment above, I have often wondered about the content on this blog, what to post and what not to post.  Where osteological articles or news are especially well covered in the national news or respected archaeological/osteological blogs (see Richard III for example), I do not think that this blog has much more to add to the in-depth coverage already written and produced.  What I hope this blog introduces is both my specialist interests and the little seen tidbits of information and useful resources.  I am particularly keen on open access sources for academic articles, especially since having finished university my own access to osteological and archaeological articles is somewhat limited.  I will also continue to post about tertiary education and how it is changing, as previously mentioned in articles on human osteology courses available in the UK and on MOOCs for example.

As stated above this blog has developed guest posts and interviews (more to come hopefully) alongside the typical posts, and I hope to further use the medium of blogging to explore different methods of communication.  Therefore there should be a photographic essay or two gracing this site within a few months, helping to show what exactly goes in archaeological departments at Universities.  From there I think many topics within our bone-obsessed realm could be opened up by photo-essays; sometimes the word can only hope to capture what a picture can capture (but we’ll see how the photographs develop first!).  Ultimately of course this blog is merely an expression of my passion and love for human osteology and archaeology, as such it remains a place where I document this.

So these are my thoughts on where this blog has come from and where it hopes to go and to develop.  We shall see what the future holds.  But dear reader, what are your thoughts, what do you want to see on the blog?

* I’ve edited this entry more times than I care to remember!

Influence:

Chapple, R. 2013.  What a Long Strange Trip It’s Been!  Reflections on Two Years of Blogging. Robert M. Chapple, Archaeologist.  (A delightful entry on the journey of blogging for the author, an Irish archaeologist, on what it has been like and what he has done.  It is certainly worth a read).

Broken Bone But Not Broke

Well I’ve managed to break my right tibia and fibula again (a minimally displaced transverse fracture), this time in the pleasant surroundings of a pub.  It’d be fair to say the pain was mitigated by a few pints, but thankfully I was also wearing the plastic splint at the time, a safety precaution after previous fractures, which kept the leg stable and safe until the NHS staff plastered it up.  The upshot is that I am finally employed, alas not in the archaeological sector, but in this environment I am very happy to have the job that I do.

I always choose green for the cast colour as it reminds me of the verdant grasses of summer and of nature; plus it is a bright colour so people will hopefully avoid running or bashing into the leg accidentally.  Take note of the bend in the tibia and fibula, and of the offset angle of the foot.  This represents a natural deformity, enhanced by several fractures of the tibia.

The break has also reminded me primarily why I started this blog in the first place, to focus on human osteology and the skeleton.  It gave me a jolt of joy to once again see my own skeleton lit up on the computer screen, to recognise one’s own skeletal idiosyncrasies.  If I manage to get a picture or a copy of the X-ray for this fracture I shall put it up as well, as it is quite informative on the effect of Polyostotic Fibrous Dysplasia, as part of McCune-Albright Syndrome, on the deformity of the long bones.  It has also highlighted the fact that the Skeletal Series posts have somewhat stalled in the last year due to the completion of the MSc and the subsequent time consuming job search.  So you should soon be seeing Skeletal Series entry 11 on the human foot.

An admittedly poor quality camera phone shot of the an X-ray of the right lower leg, ankle is bottom left. Note the location of the fracture on the mid shaft of the tibia in the red box. The tibia and fibula both exhibit a medial bowing at the mid shaft, with areas of translucence on the bone highlighting the polyostotic fibrous dysplasia lesions. The angle and location of the break indicate a failure of the tibia as a weight loading bone due to the porous quality of both the cortical and trabecular bone, particularly at the angle highlighted.

In the meantime I’ll shortly have a post up on the new facet of education that is drastically widening participation at the university level education level, the indefatigable rise of the MOOC.  I also aim to write up a quick review of a fascinating book by historian Joel F. Harrington entitled The Faithful Executioner: Life and Death, Honour and Shame in the Turbulent Sixteenth Century, detailing the life of Nuremberg executioner Meister Franz Schmidt, who kept a detailed record of his 40 plus years in the role.  It is a fascinating book and an excellent view into the legal and cultural context of the role of the executioner in Germany and Europe in this fascinating period, as well as detailing the personal crusade that Schmidt himself took in gaining acceptance into respectable society.

So until then, auf Wiedersehen!

An Introduction to Fibrous Dysplasia & McCune-Albright Syndrome

Definition of Fibrous Dysplasia: ‘Fibrous dysplasia is a non-inherited metabolic bone disease in which abnormal differentiation of osteoblast maturation (which) leads to replacement of normal marrow and cancellous bone by immature bone and fibrous stroma’ (Fitzpatrick et al 2004: 1389).  Fibrous Dsyplasia (FD) can be described as either monostotic (one) or polyostotic (many), depending on how many bones are affected by the disease.  Fibrous Dysplasia lesions are often displayed as having a ‘ground glass‘ appearance on x-rays and are a distinctive radiographic feature of the disease, although it is not pathognomonic of it (Waldron 2009).  It is also noted that pathological fractures are a key defining feature of polyostotic Fibrous Dysplasia (Marsland & Kapoor 2008).  FD is described as a rare disease, with the monostotic form being more prevalent than the polyostotic form.

Definition of McCune-Albright Syndrome:  McCune-Albright Syndrome (MAS) was originally typically diagnosed and recognised when a person had any of the two of the triad of the following symptoms: polyostotic Fibrous Dysplasia, Cafe-au-lait marks and/or precocious puberty.  However it was later recognised that ‘endocrinopathies, including hyperthyroidism, growth hormone excess, renal phosphate wasting with or without rickets/osteomalacia, and Cushing Syndrome’  could be found in association with the original triad (Dumitrescu & Collins 2008: 1).  In all three systems (skin, skeletal & endocrine), the presentation and abnormality can be highly variable from person to person depending on the tissues involved and the extent of the involvement (OMIM-see below).  Estimated prevalence is 1/100,000 to 1/1,000,000, it is such a wide margin because no thorough prevalence study has been carried out in recent times (Dumitrescu & Collins 2008: 1).

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As a person who happens to have McCune Albright syndrome, to have known to have it from the first years of life, I have become somewhat forgetful of its origin: that somewhere in the early postzygotic  divisions of my life, the disease appeared and became a part of me.  Although I am aware each day of the ramifications that the mutation of the GNAS1 gene has caused I often consider myself lucky.  Lucky in the fact that in my case it has only led to broken bones and various surgeries rather than the full expression of the endocrinopathies that can occur.  I use a wheelchair for everyday mobility with limited use of crutches, mostly used for aiding inside mobility (and sometimes excavations!).

In my personal case, the disease has most affected the main weight-bearing bones of the lower limbs (fairly typical as they are the stress bearing bones, prone to fracture from weakened bone architecture).  Generally speaking,the long bones of the appendicular skeleton tend to be bowed naturally with a pathological weakness due to the lack of normal bone density and high bone cell turnover, with the aforementioned bone lesions occurring spontaneously which sometimes lead to fracture.  This includes the bilateral deformity of the femora with which I’ve had numerous pathological fractures (Five natural transverse fractures, five elective surgery initiated) on both the left and right sides, alongside a number of fractures of the right tibia and fibula (including both transverse and hairline fractures), two on the right humerus and the 5th metatarsal in the right foot.  The shepherd’s crook deformity is the common bowing deformity with varus angulation of the proximal femur (Fitzpatrick et al 2004: online).

As stated the primary bones affected by the MAS pathological fractures are typically located in the appendicular skeleton and include the following bones in order of prevalence first:  a) femur, b) tibia, c) fibula, d) humerus and e) the ribs.  It can also affect the craniofacial skeleton with distinct abnormalities in the amount of bone growth and deformity; however this tends to lessen with age after the primary and secondary growth periods (adolescence and sexual maturity), or ‘burn out’ as it is often called by medical specialists (Dumitrescu & Collins 2008: 8).

‘An example of the shepherds crook’ deformity of the femoral neck (coxa vara) with internal fixation.

My experiences of living with McCune Albright syndrome has included numerous hospitalizations due to fractured bones and planned corrective surgeries.  This has also included large amounts of time stuck in my old friend the Thomas Splint in bed bound traction, alongside enduring a host of various corrective surgical procedures to improve the angulation of both femoral necks.  Although the initial idea following a number of fractures was to treat the femoral deformities with an Ilizarov apparatus by manipulating the bone growth every day, it was quickly decided that an intramedullary rod (nicknamed the Sheffield Rod), carried out in conjunction with osteotomies to correct the femoral neck angle during surgery, would be a much safer and further reaching goal in stabilising both femoral necks in the long term.  (A rather wonderful digital video of a rod being inserted/hammered in can be viewed here).  Five major elective intramedullary rod surgeries later (3 for the left femur and 2 for the right femur!), and it seems as if they have thus far stabilised each femoral shaft/neck enough for them not to fracture again.  However this is also due to using the wheelchair much more extensively than before!

I also have had surgery to stabilise the right tibia and fibula.  This was decided after having undergone three accidental fractures of the right tibia and fibula with a space of 5 years (when the tibia breaks the fibula often follows because of their connection via the interosseous membrane), with each fracture requiring many months in plaster in order for the bone to heal.  Again this surgery included osteotomies of the tibia and fibula to improve the angle of the bone (and thus improve the bio-mechanical loading of the lower leg) and included the fixation of the tibia by means of a titanium plate.  It was hoped that an intramedullary rod could be inserted into the tibia after the tibial osteotomy but the risk of massive blood loss (an outcome of the porous bone and increased heartbeat/blood flow) and the presence of porous cortical bone meant that the tibia was probably unlikely to be able to ‘hold’ the rod in place.

I have also fractured the right humerus twice, with the second transverse fracture resulting in the fixation of the humerus with a permanent titanium plate and associated screws.  This is similar to my right tibia which has a permanent titanium plate and screws to fixate the bone and alleviate some of the pressure of walking.

I have undertaken treatment using biphosphonphates (in my case the drug pamidronate) to increase the bone density itself over a number of years in the past when I was a teenager, but the resultant bone density scans (taken at intervals before, during and after the treatment) showed little improvement and treatment was subsequently stopped.  Upon further reading into this it seems there are possible problems for long term users of biphosphonates.   This can include the higher risk of fracture after long term use due to the bodies inability to metabolize the drug and the natural effect of the biphosphonate inhibition on the bone cell turnover rate (Ott 2005: 31897).  There are many cases though where drug treatment has proved beneficial; however each case should be merited individually and each person monitored as appropriate.  I will stress here that there are many different types of biphosphonates available and that McCune Albright Syndrome varies in its intensity.

X ray of my left femur and hip with a locking intramedullary rod and screws.  Although please note that two of the femoral neck screws have now been taken out.

Although this is just a short post on the introduction to the disease that is sharing life with me it can also be found in the archaeological record.  Waldron (2009: 214) points out that Fibrous Dysplasia is often best diagnosed in an archaeological skeleton by the noting of either a shepherd’s crook deformity, healed fractures and findings of expansile swellings on one or more bones.  Subjecting the suspected sample to X-ray should show ‘lucent areas with endosteal scalloping and sometimes a thick sclerotic border’  (Waldron 2009: 215).  Unlike today’s vast array of modern medical treatment and surgical procedures, people in the past largely had to make do and mend.

As Roberts & Manchester (2010) discuss in their book, fracture treatment in the medieval age and before was fairly adept at helping in supporting and stabilising the fracture site.  However with repeated breaks in the main weight supporting bones, it is doubtful whether one could have led a normal life if the fractures were not reduced properly or repeatedly after continual breaks (Oakley 2007).  It also should be noted here that due to the nature of McCune Albright Syndrome it is unlikely to be described in the archaeology record as human skin rarely preserves.  It is far more likely that Fibrous Dysplasia is diagnosed based on the skeletal remains.

In the archaeological record Fibrous Dysplasia remains a rare and elusive disease to diagnose, whilst is has actively been described and documented in more recent human remains (Nerlich et al. 1991).  The following two case studies highlight individual cases of where Fibrous Dysplasia has been documented in archaeological material.

A recent case study presented by Craig & Craig (2011) discusses a juvenile skeleton with evidence of polyostotic Fibrous Dysplasia.  The skeletal remains of a child aged 7 years presents with Fibrous Dysplasia with evidence of involvement most noticeable with large bone expansion on the left mandible alongside involvement of the temporal, maxilla, parietal and frontal craniofacial bones.  A review of the burial context of the skeleton and of the Anglo-Saxon cemetery population that the child comes from shows no differentiation between this and other burials, indicating no differentiation in the disposition of this child’s body or associated grave goods.  Craig & Craig (2011) also cite further Ango-Saxon literature to suggest that it is highly unlikely that the child was stigmatized due to his disability, although we can never know for sure.

Recent evidence in a 120,000 year old Neandertal individual from the Upper Pleistocene site of Krapina in present day Croatia highlights the likely evidence for Fibrous Dysplasia presence in a small rib fragment (Monge et al. 2013).  This is extremely rare to find a bone lesion or tumour  in skeletal material from such a period and it is extremely exciting.  The rib was allocated original as a faunal remain when the site was initially excavated, but the rib was recognised for being of Neandertal origin by sharp eyed human osteology legend Tim D. White (Monge et al. 2013).

X ray of the transverse fracture of my right tibia and fibula in the summer of 2009.  This was the first of three transverse fractures of the right tibia and fibula that followed in quick succession over a short number of years, and resulted in the fixation of the tibia with a permanent titanium plate.

Below are some medical and non-medical sources of information on the various aspects of both Fibrous Dysplasia & McCune Albright Syndrome (FD and MAS). This includes a few recent palaeopathology articles that are freely available, medical articles discussing both FD and MAS, core palaeopathology textbooks and support groups in the US and UK for sufferers of the bone disease.  Although the disease is not headline grabbing news, the lack of research into the socio-economic aspects of the disease is distinctly lacking, as is the number of foundations or adult support services for sufferers with the disease.

I am thankful for the support of my friends, family & my consultant in the treatment of this syndrome and for continued support given.

N.B. The origin of the Ilizarov frame is particularly interesting.  It was first used in the 1950s in the USSR, with Dr Gavril Ilizarov originally using bicycle wheel spokes to fixate, support and lengthen badly fractured bones.  It was only introduced to the West in the 1980’s as a direct result of Ilizarov’s corrective surgery on a patient in Italy when all other options had failed in healing the patient’s fractures.  So far I have managed to avoid having the frame but it is still a standard procedure for badly fragmented fractures, in particular it is often used after motorbike accidents or reconstructing limb angulation/length.

Bibliography and Further Sources:

Fibrous Dysplasia:

• Fibrous Dysplasia Support Society UK.
• Fibrous Dsyplasia Foundation.
• Magic Foundation: MAS division
• Mayo Clinic Overview of Fibrous Dysplasia.

Medical Articles:

• Burke, A. B., Collins, M. T., & Boyce, A. M. 2016. Fibrous Dysplasia of Bone: Craniofacial and Dental Implications. Oral Diseases. doi: 10.1111/odi.12563.

• Feller et al. 2009. The Nature of Fibrous Dysplasia. Head & Face.  5 (22): 1-5.

• Fitzpatrick, K. A. et al. 2004. Image Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation. American Journal of Roentgenology. 182 (6): 1389-1398.

• Lee, J. S. FItzgibbon, E. J., Chen, Y. R., Kim, H. J., Lustig, L. R., Akintoye, S. O., Collins, M. T. & Kaban, L. B. 2012. Clinical Guidelines for the Management of Craniofacial Fibrous Dysplasia. Orphanet Journal of Rare Disease. 7 (1): 1-19..

• Marsland, D. & Kapoor, S. 2008. Rheumatology and Orthopaedics. London: Mosby Elsevier.

• Ott, S. M. 2005. Long-Term Safety of Biphosphonates. The Journal of Clinical Endocrinology & Metabolism. 90: 31897-31899.

McCune-Albright Syndrome:

• Brief overview of MAS symptoms.
• OMIM entry on history and presentation of MAS.
• Detailed general and genetic overview of MAS from the Online Medelian Inheritance In Man project.

Medical Articles:

• Charpulat, R. D. 2008. Fibrous Dysplasia of Bone and McCune-Albright Syndrome.  Best Practice & Research Clinical Rheumatology. 22 (1): 55-69.

• Dumitrescu, C. E. & Collins, M. T.  2008.  Overview: McCune-Albright Syndrome. Orphanet Journal of Rare Disease. 3 (12): 1-12.

• Hannon, T. S. et al. 2003. Is McCune-Albright Syndrome Overlooked in Subjects with Fibrous Dysplasia of Bone?  Journal of Pediatrics. 142 (5): 532-538.

• Laven, J. S. E, Lumbroso, S., Sultan, C. & Fauser, B. C. J. M. 2001. Dynamics of Ovarian Function in an Adult Woman with McCune-Albright Syndrome. Journal of Clinical Endocrinology & Metabolism. 86 (6): 2625-2631.

• Parisi, M. S. & Oliveri, B. 2009. Long-Term Pamidronate Treatment of Polyostotic Fibrous Dysplasia of Bone: A Case Series in Young Adults. Current Therapeutic Research. 70 (2): 161-172.  
  

Palaeopathology:

• Aufderheide, A. C. & Rodríguez-Martín. C. 1998. Cambridge: Cambridge University Press. (pg.420-421).

• Craig, E. & Craig, G. 2011. The Diagnosis and Context of a Facial Deformity from an Anglo-Saxon Cemetery at Spofforth, North Yorkshire. International Journal of Osteoarchaeology. doi: 10.1002/oa.1288.

• Milella, M. Knüssel, C. J., & Haddow, S. D. 2016. A Neolithic Case of Fibrous Dysplasia at Ҫatalhöyük (Turkey). International Journal of Palaeopathology. 15: 10-18.

• Monge J, Kricun M, Radovčić J, Radovčić D, Mann A, et al. 2013. Fibrous Dysplasia in a 120,000+ Year Old Neandertal from Krapina, Croatia. PLoS ONE. 8(6): e64539. doi:10.1371/journal.pone.0064539 (free open access article).

• Nerlich, A., Peschel, O., Lohrs, U., Parsche, F., Betz, P. 1991. Juvenile Gigantism plus Polyostotic Fibrous Dysplasia in the Tegernsee Giant (Letter). Lancet. 338: 886-887. (please email if you pay walled and would like a copy of this article for personal use).

• Roberts, C. & Manchester, K. 2010. The Archaeology of Disease Third Edition. Stroud: The History Press.

• Traversari, M., Serrangeli, M. C., Catalano, G., Petrella, E., Piciucchi, S., Feletti, F., Oxilia, G., Cristiani, E., Vazzana, A., Sorrentino, R., De Fanti, S., Luiselli, D., Calcagnile, L., Saragoni, L., Feeney, R. N. M., Gruppioni, G., Cilli, E., & Benazzi, S. 2019. Multi-analytic Study of a Probably Case of Fibrous Dysplasia (FD) from Certosa Monumental Cemetery (Bologna, Italy). International Journal of Palaeopathology. 25: 1-8.

• Waldron, T. 2009. Palaeopathology: Cambridge Manuals in Archaeology. Cambridge: Cambridge University Press.

General Medical

• Medline Plus, a US medical site.

• Pub Med, a US National Library of Medicine website.

Broken Bones: One of My Own

An x-ray of my right tibia showing a traumatic transverse fracture in 2009.

My right tibia and fibula, with a transverse fracture gained in the summer of 2009.  A result of polyostotic fibrous dysplasia and my having MCune Albright Sydrome.  Needless to say I spent the summer reading in the sun.  The fracture took a remarkable 17 weeks to heal in a plaster cast.

Skeleton People…

Another classic article from The Onion website:

“This is an incredible find,” said Dr. Christian Hutchins, Oxford University archaeologist and head of the dig team. “Imagine: At one time, this entire area was filled with spooky, bony, walking skeletons.”

The rest of the hilarious article can be found here: http://www.theonion.com/articles/archaeological-dig-uncovers-ancient-race-of-skelet,1268/

It seems archaeologists have recently uncovered a race of ‘skeleton’ people!

On another more serious note, I’m having surgery tomorrow to remove some hardware (proximal left femur and removing of two screws from the femoral neck, plus some exploratory movement and investigation).  Now this might mean I won’t be writing here for a while depending on how surgery goes.  As I said before I have a certain bone disease, for all you human osteologist diehards out there my disease is McCune Albright Syndrome with the bone disease call Fibrous Dysplasia.  A detailed medical website describes the attributes for Albright Syndrome and its implications here.

Although I am free of any endocrine function anomalies, I do have the Polyostotic Fibrous Dysplasia element of MAS.  This had led to extensive femoral surgery alongside a good number of fractures on the long bones of the body, particularly the right tibia/fibula, right humerus, and both femora.  However, I consider myself relatively lucky considering how extreme this disease can get.  Below is an X-ray of pretty much what femora look like-

A typical femoral intramedullary rod, highlighting the extra screw into the femoral neck to stablise the femur (nicknamed Sheffield rods due to the city’s metal heritage) (source: Google).

Finding out information on MAS and PFD on the internet is hard work as not many medical articles have been wrote on the subject.  The journal of Journal of Bone and Joint Surgery naturally has a number of interesting articles on the subject of long bone deformities.  I’ll write a more detailed post later on, with my experiences of surgery and how the bone condition is managed.

So enjoy the post below on cannibalism, and I will be back shortly!