(2008) The parry problem

Journal of Archaeological Science 35 (2008) 1658e1666 http://www.elsevier.com/locate/jas The parry problem Margaret A. Judd* Department of Anthropology, University of Pittsburgh, Pittsburgh, PA 15260, USA Received 1 September 2007; received in revised form 8 November 2007; accepted 12 November 2007 Abstract Injuries classified as parry fractures, normally the result of a direct blow when the forearm is raised to shield the face, are significant in bioarcheological interpretations because the parry fracture is perceived as an indicator of interpersonal (or extramural) violence. It is therefore necessary that these injuries be correctly identified in order to properly interpret the trauma pattern and its social implications for abuse, gender and power relations among ancient people. Common acute forearm fractures are reviewed here and quantitative guidelines that define the parry fracture configuration are presented. The parry criteria include: (1) an absence of radial involvement, (2) a transverse fracture line, (3) a location below the midshaft (<0.5 adjusted distance to the lesion’s center), and (4) either minor unalignment (<10 ) in any plane or horizontal apposition from the diaphysis (<50%). A sample of 278 adults from northern Sudan dated to the Nubian Bronze Age (ca. 2500e1500 BC) contained 38 individuals with forearm fractures. Of these fractures, 21 out of the 28 ulna injuries were identified as parry fractures using the parry criteria. Fewer females suffered from parry fractures than when ulna injuries were identified by location on the ulna alone. The use of the parry criteria may not always affect the results significantly, but here interpersonal violence directed against women and amongst ancient Nubians was found to be less prevalent than implied in earlier studies. The absence of perimortem parry fractures suggests that the Kermans interred within mass burials were not physically forced to their graves. Chronic ulna stress fractures associated with sports and habitual activities must also be considered as a differential diagnosis of this injury. Ó 2007 Elsevier Ltd. All rights reserved. Keywords: Paleopathology; Trauma; Fracture; Violence; Kerma; Nubia; Sudan The right ulna was fractured. Typical case. The right ulna was fractured at a somewhat higher level than usual. (Smith and Wood-Jones, 1910: 313) 1. Introduction Injury patterns provide a means to understand ancient life ways and behavior, for example, interpersonal relations among community members, external relations, attitudes towards others, environmental or occupational hazards, medical knowledge, and also the consequences of injuries for the individual and the community (Brickley and Smith, 2006; Buzon and Richman, 2007; Judd, 2002a; Kilgore et al., 1997; Mays, * Tel.: þ1 412 624 5599. E-mail address: mjudd@pitt.edu 0305-4403/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.jas.2007.11.005 2006; Smith, 1996; Torres-Rouff and Junqueira, 2006). The ulna parry fracture is perhaps the most poorly defined and controversial injury owing to its implications for social behavior in ancient societies particularly interpersonal violence (e.g., Jurmain, 1999; Lovell, 1997). This ‘parry problem’ originates from the eponym itself, identification, association with interpersonal violence, and differential diagnosis. This investigation will (1) further refine the common acute forearm fracture pattern observed to facilitate interpretation using quantitative and qualitative criteria and (2) review the problems associated with the interpretation of the parry fracture. This was achieved first by distinguishing common acute forearm injury types by quantitative and qualitative criteria collected from clinical literature, and second, by determining the proximate injury mechanismddirect or indirect forcedfor each fracture observed among a group of individuals from Bronze Age Nubia. The usefulness of the recording measurements in fracture analysis is discussed. M.A. Judd / Journal of Archaeological Science 35 (2008) 1658e1666 2. Background to the parry problem The medical use of eponyms, such as the parry fracture, peaked during the 19th century, when fracture descriptions were established by clinical presentation and palpation until the advent of radiology in 1895 (Schultz, 1990). Fractures were frequently named to honor the physician who fully described them, for example, the fractures named for physicians Colles, Smith and Galeazzi. More picturesque fracture eponyms were derived from a specific etiological mechanism such as the boxer’s fracture, bumper fracture, clay shoveller’s fracture and baseball finger (Lee et al., 2004; Schultz, 1990). Although attempts have been made to eliminate eponym usage in current clinical practice (Kishore et al., 2000; Strous and Edelman, 2007) and systems such as the AO (Association for the Study of Osteosynthesis) fracture classification (Müller et al., 1990) have been produced, eponyms continue to remain popular in clinical literature and reference manuals. The activity-related eponyms, particularly the parry fracture, pose a problem in bioarcheological interpretation in that their very name promotes a specific injury mechanism. Lovell (1997) and Jurmain (1999) argued that ulna shaft fractures are often indiscriminately classified as a parry or its more recent eponym a ‘nightstick’ fracture (Lee et al., 2004). They observed that most bioarcheological reports referred to this injury as an isolated ulna shaft injury resulting from a blow and did not consider the involvement of the ipsilateral radius, the location of the lesion, the fracture line and the associated complications. They cautioned that the term ‘parry’ conjures an image of fending a blow, even though it may not have been the mechanism of injury and may, therefore, influence the interpretation. Interestingly, even in clinical literature, the parry fracture is identified as ‘an isolated fracture of the ulnar shaftdusually in the middle or distal third, produced by a blow and not involving the radius’ (Jurmain, 1999: 219, gleaned from a survey of clinical definitions). This qualitative definition of the parry fracture does not clarify the physical configuration of the lesion and it is understandable why a variety of ulnar (and radial) shaft injuries have been misinterpreted as a parry fracture in bioarcheological investigations. The ‘blow’ is the essential component of the definition that distinguishes this lesion from other forearm fractures and can be confirmed by an injured person in clinical settings; however, the injury mechanism cannot be ascertained from undocumented skeletons. The designation of a lesion as a parry fracture can be improved upon by a more rigorous analysis of forearm fractures to more accurately interpret behavior in past societies. A suite of specific measurements are dutifully recorded (or should be recorded) to facilitate fracture identification or to evaluate healing in trauma analysis (Grauer and Roberts, 1996; Judd and Roberts, 1999; Lovell, 1997; Roberts, 1988) and to reflect the information recorded by clinicians (Hertel and Rothenfluh, 2005). The usefulness of this information to identify a successfully healed lesion in trauma analysis has been published previously (Grauer and Roberts, 1996), but paleotrauma literature is relatively silent on the role of these measurements in defining fracture types. General definitions 1659 of acute forearm fractures derived from both quantitative and qualitative clinical descriptions can be useful in paleotrauma analysis to explicitly distinguish the parry fracture from other forearm injuries. It is essential that the presence or absence of the ipsilateral forearm bone be recorded for trauma data collection as the fracture’s isolation affects the etiological interpretation. Our neglect to indicate the presence of the adjacent bone was perhaps facilitated by the protocol favored for the systematic analysis of long bone trauma that in itself was a turning point for trauma analysis when proposed by Lovejoy and Heiple (1981) to compensate for incomplete skeletons. This method of analysis, now standard, presents the trauma frequency for each element type (number of fractured elements per number of elements observed) and the overall fracture rate (total number of fractured bones per total number of bones observed). While the numbers of individuals who bore a forearm injury involving both the radius and ulna may be stated (e.g., Grauer and Roberts, 1996; Judd and Roberts, 1999; Jurmain, 1991; Kilgore et al., 1997), the presence of the complementary bone is unreported if it is uninjured, which hinders the researcher’s interpretation of the injury mechanism. This omission was tackled by Alvrus (1999) who, in her analysis of Nubian long bone fractures, reported the presence or absence of the associated radius, injury location on the shaft and presence of rotation. A method that integrates qualitative and quantitative criteria is proposed here to facilitate fracture classification in order to determine the proximate cause of forearm fractures among individuals from two Nubian Bronze Age samples, and subsequently, enhance the injury pattern interpretation at the individual and populational levels. 3. Materials 3.1. The skeletal sample and archaeological context The data presented here derived from the general trauma analyses of two archaeological skeletal samples from the Kerma culture of Bronze Age Nubia (ca. 2500e1500 BC) (Judd, 2000, 2004, 2006); the aging and sexing methods, the demographic distribution of the sample and the elements observed are detailed in these reports. Both samples, although dissimilar in socioeconomic complexity, were found to have a high prevalence of trauma, notably forearm fractures. The identification of the injury mechanism was essential to aid in the interpretation of the funerary program present at Kerma, the capital of the Bronze Age state in Upper Nubia and adversary of ancient Egypt. The indigenous Nubian burial configuration was specific: the individual was buried in a flexed position, oriented eastewest facing north, and in addition to personal items was often accompanied by an assortment of goats, sheep or a dog (Bonnet, 1990). This changed dramatically when Kerma reached its apogee of power and social complexity during the Classic Kerma period (ca. 1750e1550 BC). At this time scores of humans replaced animals in central corridors that bisected the immense royal burial structures (Reisner, 1923). Reisner (1923), who excavated the site 1660 M.A. Judd / Journal of Archaeological Science 35 (2008) 1658e1666 between 1913 and 1916, proposed that these individuals were human sacrifices, predominantly female, who accompanied the king into the afterlife. A detailed trauma analysis was necessary to determine if perimortem trauma caused death or whether the biological, social or ethnic status of the individuals exposed them to heightened levels of interpersonal violence. Also of interest was whether the pattern observed at Kerma was similar to that of their rural neighbors (Judd, 2006). The Kerma skeletal sample is curated at the Duckworth Laboratory at the University of Cambridge Leverhulme Centre for Human Evolutionary Studies. This analysis included 223 adults (93 males and 130 females), 28 (12.6%, 17 males, 11 females) of whom bore 30 forearm injuries. The rural sample was excavated by the North Dongola Reach Survey (NDRS) in 1996 from cemeteries O16 and P37 near the modern town of Dongola, located 70 km upriver from Kerma (Welsby, 2001). The NDRS collection is curated at the Department of Ancient Egypt and Sudan at The British Museum and includes 55 adults (28 males and 27 females). Of these individuals, 10 (18.2%, 8 males and 2 females) experienced 14 forearm injuries. These samples are combined for this analysis to examine the 44 forearm injuries born by 38 individuals from the original group of 278 adults. Fig. 1. Adjusted distance to the center of the lesion: D/L ¼ distance between the center of the lesion and the distal articular surface/length of bone. 1905), 30 (Browner et al., 1992; Müller et al., 1990) and 45 (Rogers, 1992) from the transverse axis. In this study the more conservative 45 was used and measurements were taken with a goniometer. 3.3. Types of diagnostic forearm shaft fractures The quantitative data collected from each traumatized bone were used to classify each lesion by acute proximate mechanism (direct or indirect trauma) (Stimson, 1905) and common eponyms, if existing. Less common injuries that were not classified by the eponyms listed below are discussed later. 3.2. Data recorded 3.3.1. Injuries caused by indirect force Forearm injuries were examined in the following groups: 1. both bones of one forearm involved, 2. isolated radius fractures, 3. isolated ulna fractures. Data recorded for each element included: sex of individual, side injured, the presence or absence of the ipsilateral bone, the length of the injured bone, the length of the callus, the distance from the bone’s distal articular surface to the lesion’s center, the maximum unalignment in any direction, the apposition of the two fractured ends once healed and the angle of the fracture line from the horizontal plane. To account for variation in bone length among individuals, I developed an adjusted distance to the center of the lesion ratio (Fig. 1), which was calculated as follows for each long bone: 3.3.1.1. Colles’ fracture (Fig. 2a). The Colles’ fracture is associated with a fall onto the outstretched palm of the hand where the distal radius is forced posteriorly and the anterior surface undergoes tension to culminate in a transverse fracture on the volar surface. The distal ulna, particularly the styloid process, may be fractured simultaneously. The Colles’ fracture is identified by a transverse fracture line that occurs within 38 mm proximal to the radiocarpal joint (Connelly, 1981; Rogers, 1992). This is accompanied by the dorsal compaction of the distal segment, which may or may not involve the distal radioulnar joint that is essential for pronation and supination of the hand and wrist (see Mays, 2006 for a thorough review of the impairment that may result from radial deformities when the lesion is poorly healed). The adjusted distance to the lesion’s center was calculated to be 0.2 (clinical distance Distance between the center of the lesion and the distal articular surface Length of bone The average length of the ulna was calculated for each sex in order to estimate the adjusted distance to center of the lesion for individuals when bones were incomplete (female mean ulna length ¼ 259 mm; male mean ulna length ¼ 276 mm; female mean radius length ¼ 233 mm). What constitutes a transverse and oblique fracture line is also understated and controversial in the clinical literature. The transverse fracture line of a simple shaft fracture (a single break producing two bone segments only) is defined by some as 15e20 (Stimson, limit/lowest value of normal radial lengths as per Olivier (1969) ¼ 38 mm/190 mm ¼ 0.2). 3.3.1.2. Smith’s fracture (Fig. 2b). The Smith’s fracture is similar to the Colles’ injury and has been referred to as a reverse Colles’ fracture (Rogers, 1992; Smith and Floyd, 1988). The fracture appears not more than 38 mm above the radiocarpal joint, but the distal radius is angulated volarly rather than dorsally (Connelly, 1981). The fracture does not M.A. Judd / Journal of Archaeological Science 35 (2008) 1658e1666 1661 Fig. 2. Summary of diagnostic criteria for acute forearm fractures. extend into the radiocarpal joint and an associated ulna injury is uncommon (Adams and Hamblen, 1992; Rogers, 1992). Although Smith originally attributed the injury to a fall on the back of the hand when the wrist was flexed ventrally, a backward fall onto the outstretched hand or blow to the back of the wrist or knuckles are equally possible (Heppenstall, 1980; Rogers, 1992; Smith and Floyd, 1988). 3.3.2. Injuries caused by direct force 3.3.2.1. Parry fracture (Fig. 2c). The definition of a parry fracture is dependent upon its mechanism, that is, a direct blow to the forearm sustained when the arm is raised to protect the head; except for this etiology, isolated ulna fractures are rare (e.g., Hertel and Rothenfluh, 2005; Rogers, 1992; Schultz, 1990). In this position, the ulna receives the full force of the blow as it is superficial to the radius. The radius may also break if the force is excessive, although this is uncommon clinically (DuToit and Gräbe, 1979; Heppenstall, 1980). A parry fracture observed in the archaeological context can only be a ‘possible’ parry injury as the ultimate mechanism, on which the definition of the parry fracture rests, will never be known. Richards and Corley (1996) described the majority of parry fractures in quantitative terms as follows: 1. the injury occurs on the distal portion of the shaft, frequently the distal third, 2. the distal segment is minimally displaced (10 in any plane) if at all, or is less than 50% apposed horizontally in relation to the proximal segment, and 3. the line of fracture is transverse to slightly oblique. An ulna fracture that fulfils these criteria, but is not the result of a direct blow, therefore, is not really a parry fracture and is verbosely referred to as ‘an isolated fracture of the ulna shaft without radial involvement’ (Richards and Corley, 1996: 911). In this analysis, the parry fracture was identified by: 1. 2. 3. 4. the absence of radial involvement, a transverse fracture line, a location below the midshaft, and either minor unalignment (10 ) in any plane or horizontal apposition from the diaphysis (<50%). 3.3.3. Injuries caused by a direct or indirect force 3.3.3.1. Monteggia fracture (Fig. 2d). Bado (1967) named the proximal ulna fracture with a displacement of the radial head after Monteggia who reported it in 1814. The distal humeral epiphysis may also be involved and the fracture nearly always occurs above the proximal third of the ulna (Rogers, 1992; Wilson and Cochrane, 1925). The fracture does not divide the supinator and pronator muscles and, therefore, little 1662 M.A. Judd / Journal of Archaeological Science 35 (2008) 1658e1666 rotational deviation occurs with this injury. The injury is due to a fall against a sharp edge or direct blow to the posterior forearm when the forearm is raised very high in front of the face to deflect a blow (Adams and Hamblen, 1992; DeSouza, 1968; Heppenstall, 1980; Rogers, 1992). 4. Results 4.1. Both forearm bones fractured Of the 38 individuals with forearm trauma, four (10.5%) exhibited injuries to both bones of the same forearm (Table 1). Of note were the multiple injuries of individual P37-J3-44. A well-healed paired rotational injury was present (Fig. 3) in addition to an ununited left radial injury received during pronation and a Smith’s fracture. As the Smith’s fracture is unlikely to occur concurrently with the rotational injury, it was sustained at some point in time prior to or following the rotational injury, although both may have occurred in sequence during a single traumatic event. The configuration of K-XB/QC’s associated forearm fractures suggested that a direct crushing force caused the injuries rather than an indirect force if simultaneous. The forearm fractures suffered by a Kerma female (K-1801D) were uncharacteristic of a fall on an outstretched hand owing to a large disparity in the distances between the lesions on the two bones and may indicate a temporal lag between injury episodes. The radial fracture line was transverse, but slightly rotatedda configuration more likely acquired from absorbing a direct force. The final adult (P37-G3-23) with combined forearm lesions presented a Colles’ injury and a medioposteriorly angled oblique ulna fracture. 3.3.3.2. Galeazzi fracture (Fig. 2e). Single radius injuries are unstable and result in some dislocation of the distal radioulnar joint (Rogers, 1992; Schultz, 1990). These injuries are most commonly proximal to the junction of the middle and distal thirds of the bone and the fracture line is oblique. They involve a noticeable rotational deformity and nonunion or malunion between the fragments unless treated with open surgery. The rotational deformity occurs due to the action of the pronator teres. The proximal radial fragment is forced into pronation across the ulna when the fracture occurs below the muscle insertion or into supination when the fracture occurs above the pronator teres insertion (Ralston, 1967). 3.3.3.3. Paired rotational fracture (Fig. 2f). Fractures involving the paired radius and ulna are easily identified by the gross deformity caused by rotation of the bone shafts. The Galeazzi and paired rotational fractures are the results of an indirect force, such as a fall on the outstretched hand, where the force of the impaction is transmitted up the bone shaft to produce an oblique fracture line. A direct blow, identified by a transverse line may fracture the radius or cause both bones to break simultaneously, but is rare in clinical cases due to the protective position of the radius in relation to the ulna when the arm is raised to defend the head (Adams and Hamblen, 1992; DuToit and Gräbe, 1979; Heppenstall, 1980; Rogers, 1992; Schultz, 1990). 4.2. Isolated radius fractures Seven additional individuals suffered isolated radial fractures, which were complemented by an uninjured ipsilateral ulna and were characteristic of an indirect injury mechanism (Table 1). The fractures displayed by the females conformed to the classic Colles’ fracture pattern. Individual K-XB/VA suffered additional soft tissue trauma to the fibular malleolus, a lesion attributed to ankle adduction that may have precipitated a fall (Adams and Hamblen, 1992; London, 1991; Rogers, 1992; Schultz, 1990). 3.4. Analysis Chi-square analysis and the Yate’s correction for small samples (n < 5) were used to assess the nominal variables. The statistical significance was set at 0.05 for all tests. Table 1 Combined forearm and radial fractures Individual Sex Ulna S K-1801D P37-J3-44 K-XB/QC P37-G3-23 M M F F K-1024A K-1058A P37-J3-36 P37-J3-44 P37-K3-48 K-1045X K-1025 K-XB/VA L R R R Radius BL 291 250 258 244 LL 46.0 54.0 20.0 34.0 DC 44.0 98.0 16.5 62.0 AJ AL 0.2 0.4 0.1 0.3  13 20 0 10 AP 100.0 0.0 100.0 100.0 FL  10 56 10 30 FX T RO T T S BL LL DC AJ AL  AP FL FX  L R R R 272 234 239 223 62.3 45.0 35.0 4.0 31.2 92.0 60.7 8.0 0.1 0.4 0.3 0.1 0 20 10 15 100.0 0.0 100.0 100.0 10 60 15 5 U RO RO C M M M M L* R* L* L* 270 255 234 25.0 35.0 34.5 34.0 130.0 102.0 75.0 1.0 0.5 0.4 0.3 0 67 15 20 0.0 64.0 75.8 0.0 0.0 60 35 35 ES RO RO RO M F F F R* L* L* R* 36.6 26.0 5.0 33.1 57.5 10.0 14.5 16.5 0.2 0.1 0.1 0.1 14 24 5 12 100.0 100.0 100.0 100.0 10 19 <5 <5 RO C C C 264 238 K, Kerma context; M, male; F, female; S, side; L, left; R, right; *, ipsilateral bone present; BL, bone length (mm); LL, lesion length (mm); DC, distance to centre of lesion (mm); AJ, adjusted distance to centre of lesion; AL, maximum unalignment; AP, apposition; FL, fracture line; FX, fracture type; T, transverse fracture; U, crush fracture; RO, rotational fracture; C, Colles’ fracture; ES, EssexeLopresti fracture; SM, Smith’s fracture. 1663 M.A. Judd / Journal of Archaeological Science 35 (2008) 1658e1666 Fig. 3. Right radius and ulna paired rotational fracture showing gross deformity of shaft and nonunion of the ulna. Among the males, K-1024A exhibited a depressed radial head that resulted in the disruption of the distal radioular jointdan uncommon injury received during a fall onto an outstretched hand referred to as an EssexeLupresti injury (Jungbluth et al., 2006). Three male single radial injuries were typical of those obtained from a fall on an outstretched hand and clearly displayed some degree of shaft rotation. 4.3. Isolated ulna fractures Twenty-eight single ulna injuries occurred among eight females and 19 males (Table 2; Fig. 4), and of these fractures, 21 were identified as parry fractures according to the metrical and macroscopic criteria. Three additional injuries fulfilled all of the quantitative criteria for a parry type lesion except that the ipsilateral radius was absent. Two females displayed ulnar head trauma (K-IV427A and K-XB/PB), which may be the result of a direct blow or sudden twisting action often accompanying an indirect force (Jakab et al., 1993). A third female ulna injury (K-K420A) not classified as a parry fracture was an unaligned oblique injury. A similar fracture configuration was observed on one male ulna (K-1065II/1) where the distal shaft was completely unapposed medioposteriorly and formed a distinctive ‘S-shape’. 5. Discussion The configuration of 21 out of 32 ulna shaft fractures met all proposed criteria for a parry fracture, except for the actual ultimate mechanism, the ‘blow’. When extrapolated to include the entire sample 1.9% of females (3/157) may have participated as a victim, attacker, or opponent in a violent encounter. A more liberal estimate of interpersonal violence would include all direct force injuries where the radial involvement was unknown, but other parry criteria were met. In this sample, four additional females were likely involved in a violent episode with another human or an object. A direct force that crushed the ulna head, but did not affect the radius was responsible for at least one other ulna fracture among females. The Table 2 Single ulna fractures Individual Sex Side BL LL DC AJ AL AP FL Type MC K-III301 K-307/A K-449B K-2355 K-XB/MB K-337A K-448B K-1805A/1 K-IVA/JA K-1045IIIF K-2000C K-IVB/AM K-XB/ZC P37-J3-48 P37-J3-46 P37-K4-28 P37-K4-28 P37-K3-31 P37-G4-36 K-1058D K-1805AC K-XB/ZC K-K420/I P37-F3-22 M M M M M M M M M M M M M M M M 266 265 265 280 293 244 273 285 284 268 273 296 277 283 50.4 24.0 30.5 36.0 53.7 28.7 28.0 45.2 32.5 35.0 37.1 30.0 43.6 51.5 39.0 39.9 36.8 50.8 61.6 30.0 22.0 20.0 27.2 27.3 130.0 85.1 93.4 133.0 45.0 59.3 23.0 89.6 55.0 95.0 18.0 46.0 76.2 60.0 40.0 48.1 57.6 35.0 60.0 30.0 25.0 18.0 96.0 36.2 0.5 0.3 0.4 0.5 0.2 0.2 0.1 0.3 0.2 0.4 0.1 0.2 0.3 0.2 0.2 0.2 0.2 0.1 0.2 0.1 0.1 0.1 0.4 0.1 5 0 5 0 0 0 10 5 10 5 0 5 10 10 15 10 10 10 14 15 5 10 5 5 100.0 100.0 100.0 100.0 100.0 100.0 55.5 100.0 100.0 100.0 100.0 100.0 100.0 77.0 78.3 100.0 100.0 90.0 95.0 70.0 100.0 100.0 100.0 100.0 10 20 5 30 M M F F F F F L* L* L* L* L* L* L* L* L* R* R* R* R* L* L* L* R* R* R* L L L L* L* 7 17 5 5 17 45 15 19 Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry Parry D D D D D D D D D D D D D D D D D D D D D D D D K-1065II/1 K-K420A K-IV427A K-XB/PB M F F F R* L* L* R 18.0 45.8 24.0 6.0 46.0 30.0 7.0 4.0 0.2 0.1 0.1 0.1 19 14 Head Head 100.0 72.0 60 60 Oblique Oblique Crush Crush I I U U 263 261 283 271 244 263 257 305 10 28 45 10 10 22 17 20 15 K, Kerma context; M, male; F, female; S, side; L, left; R, right, *, ipsilateral bone present; BL, bone length (mm); LL, lesion length (mm); DC, distance to centre of lesion (mm); AJ, adjusted distance to centre of lesion; AL, maximum unalignment; AP, apposition; FL, fracture line; T, fracture type; MC, mechanism (I, indirect force; D, direct force; U, uncertain). 1664 M.A. Judd / Journal of Archaeological Science 35 (2008) 1658e1666 Fig. 4. Ulna parry fracture showing lack of unalignment, fusiform swelling, location on distal third of ulna shaft. involvement of females in interpersonal violence, therefore, may have been as high as 5.1% (8/157), but the absence of the telltale ipsilateral radius weakens the argument. Had the parry lesion been identified simply by occurring on the ulna 6.4% of females (10/157) would have exhibited the lesion, which is significantly greater than the females with injuries that met the full parry criteria (3/157; c2 ¼ 0.16, P ¼ 0.05). When elements were considered a significant difference was also observed (3/194 vs. 10/194; c2c ¼ 0.13, P ¼ 0.05). In this case, the role of females in violent confrontations is significantly overestimated when the parry criteria are not applied. The parry criteria did not significantly alter the frequency of ulna injuries attributed to direct force among males. Nineteen out of 121 males (15.7%) bore 20 direct force ulna fractures, while ulna injuries to the two remaining males were characteristic of an indirect force. Males experienced a significantly higher frequency of ulna injury (19/121) due to a direct force than the females (3/157; c2c ¼ 15.99, P < 0.00) when the parry criteria were applied. Had parry fractures been identified by location on ulna alone (21/121 males, 10/157 females) a significant difference would also have been observed between the sexes (c2 ¼ 8.32, P ¼ 0.00). Not only do these results liberate ancient Nubian males from the unflattering image of violent wife-abusers that was initiated by Smith and Wood-Jones (1910), but they have broader implications for the Kerma funerary program. The lack of perimortem defensive parry fractures and perimortem trauma in general suggests that the individuals went to their deaths willingly or at least were not physically forced. When levels of interpersonal violence using the parry criteria were compared for individuals interred within the royal burial corridors to those interred outside of the corridors, no significant difference was observed between the subgroups or sexes (Judd, 2002b; Judd et al., 2006). Individuals interred in the mass burial were at no greater risk to interpersonal violence or habitual abuse than those interred elsewhere. The absence of perimortem injuries and lack of differential levels of interpersonal violence has forced researchers to consider other factors for inclusion in the communal burials such as ethnicity, biological affinity, health status and the cultural value of being included in the mass interment (e.g., Judd et al., 2006; Buzon and Judd, in press). 5.1. Etiological problems The parry criteria aid in identifying the proximate mechanism of the fracture (i.e., direct or indirect force), but limitations remain. First, we will never know the ultimate mechanism. Under what circumstances was the injury received and what was the individual’s behaviour? Was the injured individual an assailant, a victim, or a participant in a sport or mutually agreeable confrontation? For example, among the Bronze Age Nubians presented here, sports such as stick fighting on land and water were popular and must be considered in the interpretation (Carroll, 1988; Filer, 1997). This interpretational predicament also holds for injuries associated with falls, such as the Colles’ and Smith’s fractures. Did the individual acquire the injury during a fall caused by their own clumsiness, a sporting event or a push during an altercation? The second unresolved problem is the sequence of the healed injuries. Each bone type heals at a different rate, which varies among individuals and is mediated by the individual’s health and life history stage. If all injuries are completely healed at the time of death we are unable to determine the order in which they occurred. An accumulation of healed injuries may provide insight into an individual’s occupation, habitual activity or behavior (Hershkovitz et al., 1996; Judd, 2002a; Wakely, 1996). Alternatively, the injuries may be the unfortunate result of one event. Furthermore, it is difficult to determine if an injury predisposed an individual to other health problems, such as osteoarthritis, or whether health problems predisposed the individual to trauma. A third problem concerns differential diagnosis. The parry fracture may easily be confused with the chronic ulna stress fracture (e.g., Kitchin, 1948). Though not as common as lower body stress fractures, ulna diaphyseal stress fractures are an increasingly reported sports injury (Jones, 2006). The ulna stress fracture does not involve the radius and it is frequently the result of a force bearing down at 90 to the ulna midshaft while the forearm is supinated and flexed at a 90 angle from the elbow to facilitate lifting heavy loads. Alternative stress fracture mechanisms include repetitive flexion and extension at the elbow, increased flexor muscle activity, and torsional stress created during rapid alternating forearm pronation and supination with flexor muscle wrist activity (Hsu et al., 2005). These mechanisms and subsequent injuries may occur during farming activities, for example, hay and manure shovelling (Evans, 1955; Kitchin, 1948; Troell et al., 1941); sports, such as rowing, weight-lifting, golf, tennis, fencing, and bowling (Hamilton, 1984; Hsu et al., 2005; Jones, 2006; Koskinen et al., 1997); and other miscellaneous stressful actions (Morris and Blickenstaff, 1967). The incomplete stress fracture is indistinguishable from the healed parry fracture when the etiology of the injury is unknown even in clinical practice. The stress lesion is characterized by: (1) perfect alignment, (2) smooth layers of periosteal bone that form a ‘spindle-shaped’ or fusiform swelling around the shaft, and (3) location at the junction of the middle and distal thirds of the shaft (Morris and Blickenstaff, 1967; Rogers, 1992). Early treatment of the painful palpable stress fracture consists of abstinence from the activity or perhaps a simple cast only (Brukner, 1998; Jones, 2006). Closer examination of the parry fractures from this sample revealed that six of the ulnae belonging to urban individuals (K-307/A, K-337A, K-2000C, K-2355, K-XB/MB and K-XB/QC) exhibited no unalignment, were in 100% apposition and may in fact have M.A. Judd / Journal of Archaeological Science 35 (2008) 1658e1666 been stress fractures. While stress fractures have been proposed as an alternative to the parry fracture in bioarcheological analysis (Alvrus, 1999; Lovell, 1997), the clinical underreporting of this injury makes it difficult to ascertain a reasonable frequency among a population or occupation. Finally, skeletal injuries represent no more than 40% of all injuries acquired during assaults (e.g., Geldermalsen, 1993; Matthew et al., 1996). Soft tissue injuries due to cuts, bruising and more fatal internal damage are invisible and as a result any bioarcheological interpretation of interpersonal or external interpersonal violence, or the lack of it, will always be underestimated no matter how many parry fractures are present. Large clinical studies almost invariably report that isolated ulna fractures are infrequent with respect to other injuries (0.2 cases per 1000 population), but are almost always the result of a direct blow to a raised forearm (Dymond, 1984; Mackay et al., 2000; Mudgal and Jupiter, 1999). This being the case, a high frequency of isolated ulna injuries relative to other fractures in an ancient society should be considered as a valid indicator of interpersonal violence. 6. Conclusions Standard measurements have previously been utilized to assess healing success of fractures and knowledge of medicine within a society, but also aid paleopathologists in identifying fracture types in order to better determine interpersonal relations, occupation, activity and environmental challenges faced by ancient people. The identification of parry fractures, normally the result of a direct blow when the forearm is raised to protect the face, is significant in bioarcheological interpretations as the parry fracture is associated with interpersonal and extramural violence. Such interpretations must be made with care as they place an ancient society in a potentially uncomplimentary position that affects how we perceive their familial, social and political relationships, as was the case of the Kerma people. It is therefore necessary that we be as accurate as possible when identifying these injuries. Allocation of forearm fractures to types and mechanisms has previously been based on broad qualitative observations, even though a range of measurements is normally collected during paleotrauma analysis. Quantitative guidelines that define the parry fracture configuration allow for greater ease to objectively compare common forearm injuries rather than rely solely on subjective verbal descriptions. These parry criteria include: 1. the absence of radial involvement, 2. a fracture line 45 , 3. a location below the midshaft (<0.5 adjusted distance to the lesion’s center), and 4. either minor unalignment (10 ) in any plane or horizontal apposition from the diaphysis (<50%). The addition of this information may not always affect the results significantly, but if the proximate mechanism of the forearm fracture can be determined more reliably, the involvement 1665 of other injuries experienced by the individual may enhance our interpretation of their social behavior and lifestyle. Acknowledgements Financial support was generously provided by the Social Sciences and Humanities Research Council of Canada (SSHRC Award 752-96-1319), the Faculty of Graduate Studies and Research (University of Alberta), the Department of Anthropology (University of Alberta) and the Boise Fund (University of Oxford). Vivian Davies (The British Museum) permitted the NDRS collection to remain at the University of Alberta for the duration of my PhD. The project director, Derek Welsby (The British Museum), team members and local Kasura workmen of the 1996/1997 NDRS excavation are especially thanked. Director General Hassan Hussein Idriss (National Corporation for Antiquities and Museums in Khartoum, Sudan) is acknowledged for his support of the NDRS project. Robert A. Foley and Maggie Bellati (University of Cambridge) were most helpful with arranging access to the Duckworth Collection. I am most grateful to Claire Thorne for providing the line drawings and Becky Redfern (The British Museum) for additional access to the NDRS collection. The author thanks Nancy Lovell, Owen Beattie, M. Anne Katzenberg, Charles Merbs, and Pamela Willoughby for their helpful suggestions. The comments of the four anonymous reviewers were most appreciated. References Adams, J., Hamblen, D., 1992. 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