Abstract We present the oldest documented case of femoral
neck fracture of a particular person in the history of
orthopaedic surgery. Examination of the skeleton of
Charles IV, the King of Bohemia and Roman Emperor living
in XIVth century has revealed a fracture of the left
femoral neck. This fracture was most probably an indirect
cause of his death as it resulted in pneumonia, the immediate
cause of death. This fact has been confirmed by contemporary
chronicles.
Introduction
Fracture of the femoral neck as a specific injury has been
known since the time of Galen. In the Middle Ages it was
reported by Ambroias Parré, the personal doctor of four
French kings [3]. The modern history of the investigation
of this injury started two centuries ago when Sir Astley
Cooper [1] described the first cases and subdivided fractures
of femoral neck into intracapsular and extracapsular
ones. To our knowledge, there exists no specific description
of an older case of a femoral neck fracture.
Case report
The senior author has been dealing for almost 40 years with the
investigation of skeletal remains of the Bohemian royal dynasties,
the House of Přemyslides and House of Luxemburg in particular.
As part of this research, on the occasion of the 600th anniversary
of his death, the skeletal remains of the most outstanding
Bohemian ruler, the King of Bohemia and Roman Emperor
Charles IV, were examined.
Charles IV, the son of John of Luxemburg and Eliška of the
Přemyslides, was born on May 14, 1316. Since 1346 he had been
the Roman and Bohemian King, and in 1355 he was crowned Roman
Emperor. For his political merits and the depth of his knowledge,
he is considered one of the most prominent European rulers
of the culminating Middle Ages. Among his most outstanding
deeds was the foundation of a university in Prague in 1348 that
still bears his name today. Charles IV died on November 29, 1378,
in Prague.
Jan Bartoníček · Emanuel Vlček
Femoral neck fracture – the cause of death of Emperor Charles IV
Arch Orthop Trauma Surg (2001) 121:353–354 © Springer-Verlag 2001
Received: 19 July 2000
CURRENT PROBLEM CASE
J. Bartoníček (౧)
Orthopaedic Clinic of 3rd Medical Faculty, Charles University,
Šrobárova 50, 10034 Prague 10, Czech Republic
J. Vlček
National Museum,
Václavské nám. 68, 10100 Prague 1, Czech Republic
Fig.1 The anterior aspect of the right and the left proximal femur
Fig.2 Xeroradiograph of both proximal femurs
A detailed anthropological analysis of the almost complete
skeleton of Charles compared with the skeletal remains of his ancestors
and descendants has revealed remarkable facts complementing
the historical image of the Emperor. Apart from the congenital
skeletal anomalies inherited from the Přemyslides and Luxemburgers,
the analysis revealed symptoms of a number of traumatic
and degenerative changes. Among the most significant was
a complicated fracture of the mandibula, a fracture-dislocation of
the lower cervical spine, and symptoms of chronic gout. All these
findings have been published before [7, 8, 9].
A surprising finding has been brought to light by the examination
of his left femur (Figs.1, 2), revealing a fracture of the femoral
neck passing 1 cm on its superior surface and 3 cm on the inferior
surface from the edge of the articular cartilage of the femoral
head. On the posterior aspect a small triangular fragment (22 × 16 ×
17 mm) was impacted in the lateral part of the neck. From the present
viewpoint this is a clear case of an intracapsular fracture of the
femoral neck with a posterior comminution and an almost vertical
fracture line of Pauwels III type. Despite a careful examination
which eliminated the post-mortem origin of this fracture (i.e. manipulation
of the remains), no symptoms of healing have been
found.
Discussion
This finding suggests that Charles IV died of the fracture
of the femoral neck which he sustained during a fall or
jump (e.g. from stairs, horse). Most of the above-mentioned
as well as other unmentioned injuries and degenerative
changes may be correlated with historical sources
and pictures of Charles IV, particularly the injury of the
cervical spine and fracture of the mandibula. However,
historical sources include only very general data about the
causes of his death. On November 2, 1378, the Emperor
issued the Minting Order together with his son Wenceslas
IV, and his last letter dated November 25 was addressed to
the Archbishop of Cologne [2]. From then until his death
there are no other details. Only the Czech historian F. Palacký
[4] writes that ‘a mischievous fever too prematurely
put an end to his blessed life in 63rd year of age…’ Until
this latest research, historians considered the primary
cause of the death of Charles IV to be the gout from which
he had been suffering in the last years of his life and
which made him bedridden [5, 6] and finally resulted in a
fatal case of pneumonia. We can now document, however,
that the death was beyond any doubt caused by the fracture
of the left femoral neck sustained sometime after November
2, 1378.
Today we can only speculate to what extent this fracture
influenced the historical development of Central Europe.
However, in any case the Roman Emperor and King
of Bohemia Charles IV is the first historically documented
person to sustain a fracture of femoral neck and
die as a result.
References
1.Cooper A (1822) A treatise on dislocations and on fractures of
the joint. Longman, London, pp 11–75
2.Kafka F (1998) Charles IV. History of a great ruler (in Czech).
Mladá Fronta, Prague
3.Metz CW, Sellers TD, Feagin JA, Levine MI, Onkey RG, Dyer
JW, Eberhard EJ (1970) The displaced intracapsular fracture of
the neck of the femur. J Bone Joint Surg Am 52: 113–117
4.Palacký F (1939) History of the Czech nation in Bohemia and
Moravia (in Czech). L. Mazač, Prague
5.Siebt F (1999) Charles IV. Emperor in Europe (in Czech). Lidové
noviny, Prague
6.Spěváček J (1979) Charles IV. His life and work (in Czech).
Svoboda, Prague
7.Vlček E (1979) The likeness and physical characteristics of Emperor
Charles IV. Folia Morphol Prague 27: 99–117
8.Vlček E, Ramba J (1991) Fracture of articular processes of the
mandibula in the Bohemian King Charles IV (in Czech). Časopis
lékařů českých 130: 404-407
9.Vlček E, Šmahel Z (1998) Roentgencephalometric analysis of
skulls of the Luxemburgs, the second Bohemian royal dynasty.
Acta Chir Plast 40: 115–127
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