A Healed Intertrochanteric Femur Fracture, Shoulder, and Rib Fractures in an Ancient Nubian Female: An Osteoarchaeological Perspective

Abstract

This report is a case of a healed proximal intertrochanteric femur fracture nonunion in an ancient Nubian adult female, approximately 58 years old at the time of death, from the Tombos archaeological site in present day northern Sudan. Tombos was founded as an Egyptian colonial town during the New Kingdom Period (14001070 BC). The individual was radiocarbon dated to 1114-910 BC and also exhibited healed fractures of the left proximal humerus and ribs. There was shortening and mild atrophy of the right femur compared to the left; radiographs demonstrated a varus deformity of the proximal femur with associated retroversion. Bone density analysis revealed that the tissue mineral density z-score for this individual was -0.798, with the z-score for Tombos females 15-24 years old being 0.396, or a total difference of 1.194. This indicates that the individual was osteopenic but not osteoporotic prior to demise. This is an important case as it occurred approximately 3000 years ago and is the oldest known reported case of a healed intertrochanteric hip fracture in the archaeological literature. Archaeological cases of intertrochanteric hip fractures are rare, with none previously reported from the BC era. The timing of these multiple fractures is unknown, but all healed before the demise of the individual. Thus, there must have been considerable care afforded to such an individual to minimize the morbidities associated with nonoperative care of such a fracture. If all these fractures occurred at the same time due to a traumatic, accidental injury, the Modified Injury Severity Score (MISS) would be 25. Modern day trauma resuscitation and orthopaedic care gives an estimated mortality for such a MISS score of 28% for those <50 years old. It is likely that this individual's high socioeconomic status allowed for intensive nursing care which likely decreased the morality risk.

Figure 1

Frontal photographs of both femora. Note the significant shortening and the varus deformity of the proximal right femur (This is an original figure created by the authors of the manuscript). (a) Anteroposterior view. (b) Posteroanterior view.

Figure 2

Radiographs of the entire femur (This is an original figure created by the authors of the manuscript). (a) Anteroposterior projection. (b) Lateral projection. Note that with the femoral condyles rotationally the same (solid yellow arrow), there is retroversion of the femoral head/neck relative to the shaft (hatched lines).

Figure 3

Anteroposterior radiograph of the hip (This is an original figure created by the authors of the manuscript). (a) Without markings. (b) Markings that demonstrate the greater trochanter abducted and medially displaced (yellow asterisk) along with exuberant callus in the region of the lesser trochanter (solid yellow arrow). The faint appearance of an old fracture line can be seen (hatched line and thin yellow arrows).

Figure 4

Photographs of the physical specimen focused on the proximal femur (This is an original figure created by the authors of the manuscript). (a) The same position as in the radiograph. (b) The major fracture line denoted by yellow asterisks. (c) A view from directly medial to lateral. Note the clearly seen, well-healed fracture (yellow arrows) exiting just inferior to the lesser trochanter and the retroversion of the proximal femur superior to the fracture line.

Figure 5

Comparison of the Tombos specimen to a present-day fracture in a present-day patient (This is an original figure created by the authors of the manuscript). (a) The AP radiographs of the present-day individual; note the marked adduction of the distal femoral shaft. (b) The AP radiograph of the healed fracture in the Tombos individual. (c) The lateral radiograph of the present-day individual; note the retroversion of the femoral neck and head. (d) The lateral radiograph of the healed fracture in the Tombos individual.

Figure 6

Photograph of the healed rib fractures (yellow arrows) (This is an original figure created by the authors of the manuscript).

Figure 7

A well-healed fracture of the left humerus surgical neck (This is an original figure created by the authors of the manuscript). (a) An anteroposterior photograph of both the right and left humerii. Note the shorter left humerus; the left humerus was 309 mm in length and the right one was 323 mm in length. (b) A close-up photograph of the left proximal humerus demonstrating a varus neck shaft position with inferior displacement of the humeral head. (c) An anteroposterior radiograph of both proximal humerii. Note the internal callus of the left humerus denoting a well-healed longstanding fracture (yellow arrow). (d) A lateral radiograph of the left proximal humerus demonstrating the internal callus (yellow arrow) and distorted surgical neck. Malunions such as this are common in fractures of the humeral neck treated nonoperatively [22].