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A Personal Anthropology of Driving

12 Mar

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 legit legal driver no longer in his 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.

right humerus fracture 2014 july

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).

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‘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‘s 13 Songs to the emotional tape loops of Steve Reich‘s 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 CD’s with new albums I’ve purchased more recently, such as Joanna Newsom‘s Divers, Godspeed You! Black Emperor‘s 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.

DSCN0508

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

22 Aug

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).

right humerus fracture 2014 july

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.

fractured right tibia digistied diseases 0365

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 Surgery4 (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 Journal1 (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.

A Humerus Tale

7 Jul

After a tremendous time volunteering for the recent Rothwell medieval ossuary open day last weekend, and having taken part in the University of Sheffield Castleton field school for a few days afterwards (nothing beats excavating skellies in the beautiful peak district!), I had the rather unfortunate occurrence of fracturing my right humerus (upper arm bone) early last week.  Following surgery to fixate the rather stark break with the insertion of a permanent plate and screws, I remain rather immobile.  Being predominately right handed this means that posts on this site will take longer to write and produce as I cannot move the right arm.  However there should hopefully be a number of upcoming guest posts so please stay tuned.

Whilst I was volunteering at Rothwell, helping as I was to inform members of the public on how osteologists age and sex skeletal material and the limitations of the methodologies, it really made an impression on me how important it was to engage with the public face to face , especially on discussing the importance of human osteology in archaeology.  As such it is a future aim of mine to become more fully involved in outreach work.  But first I need to heal and normally for someone with McCune-Albright Syndrome this means that it could take some time.  If I can I’ll put up a picture of the x-ray as it really was an impressive full break!

As such I want to re-iterate the clarion call for guest post entries and for blog interviews across a range of osteological and archaeological themes.  Please feel free to contact me and send me an email for further information.

Pain, Briefly

17 Jun

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.

chestxray22222

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 SyndromeOrphanet Journal of Rare Disease3 (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.

Broken Bone But Not Broke

6 Jul

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.

OLYMPUS DIGITAL CAMERA

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.

remake2013july

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!