The Skeleton (Fractures and Treatments)¶
Types of Fractures¶
In the system fractures are categorized as either ‘open or closed’. If the medical records do not specify whether or not the fracture is open or closed, it is suggested that it be entered as a closed fracture.
Closed Fractures Found in Medical Records / X-rays¶
· Avulsion – portion of the bone is pulled away near the muscle attachment
· Comminuted – a crushed bone or fragmented bone
· Compression – two vertebra surfaces are driven together
· Impacted – part of one bone is driven into another
· Incomplete – break does not completely sever the bone
· Greenstick – incomplete fracture of a long bone, usually in children
· Spiral – long bone fracture in a spiral formation
· Hairline - fracture refers to a thin break in the bone
· Transverse - fracture in a long bone that is crosswise or straight across the shaft of the bone
· Displaced and non-displaced describe the state of the bone fragmentif the fragments are in good position then it is termed a non-displaced fracture, whereas if the fragments are out of line it is a displaced fracture
Open Fractures Found in Medical Records / X-rays¶
· Compound - bone fragment pierces the skin
Fracture Treatment¶
Medical reports will contain information on whether the treatment of the fracture was open or closed. This description of the type of procedure should not be confused with the ‘open and closed’ type of fracture; the two will not necessarily match.
Selection of brace/splint/cast treatment based on the medical records¶
· There are various types of braces, splints and casts and some even have specific names based on the body part injured.
· The system contains treatment codes for the basic/routine types of braces/casts/splints most frequently used in association with fractures, dislocations and sprain/strain type injuries.
· If you have trouble determining the correct code to use, we recommend using the Treatment Protocol tab for associated immobilizers and a review of the Medical Library text to help determine the code that most closely matches the medical records. The system treats all braces/splints/cast similarly so if there is not an exact match there is no impact to the case value.
· Code as a treatment when first applied
· No code is needed for removal of cast
· If problems with cast (improper fitting) or cast is damaged and has to be replaced, code with 'Replacement of cast ' codes.
Closed Reduction – bones are aligned manually and held into place, no incision¶
Open Reduction – bones are aligned using a surgical technique¶
Internal Fixation – bones are held into place by hardware { #Internal_Fixation–bones_are_held }¶
· Application of the hardware is included in the internal fixation procedure
· Internal fixation devices (plates, rods, pins, screws, wires and nails) are used in closed and open reduction
· In closed reduction the hardware is placed percutaneously , or through the skin, without a surgical incision.
· Open reduction involves a surgical incision to access the bone and place the hardware.
· One of the most common pieces of hardware is referred to as “intramedullary nail” and is commonly seen in association with a closed reduction of a fracture
· Some other terms seen in relation to internal fixation might refer to the name of a screw or pin along with the measurements. Examples:
o 6.5 mm cancellous screws,
o 70 x 20 mm threaded EBI pins,
o Cortical screw
· All the treatment codes in the system that include ‘with internal fixation’ include the hardware , there is no separate coding required to account for the use of hardware or to identify what hardware was used
Hardware Removal¶
· In cases where the internal fixation/hardware is later removed, the remova l of the hardware is coded separately in the system along with the appropriate Medical Occurrence Date
· To locate the code for ‘removal of hardware’ freeform search on the key words ‘hardware removal’ along with the name of the bone involved or
· Click the Treatment Protocol tab on Medical Details and make the appropriate selection from the Medical Condition dropdown. The hardware removal codes are described as “Removal of implanted devices from bone”
External Fixation¶
· In the treatment of bone fractures, the use of externally placed plates or rods is used to keep the parts of the broken bone in place. The external plates or rods are fastened to the bones by means of pins or screws that penetrate the skin and flesh overlying the affected bones.
· The medical treatment in the system, 'Insertion of External Fixation Device' assumes the removal of the external fixation
· The removal is not put in as a separate treatment.
- The root codes for external fixation as a treatment are 0PH and 0QH
Fusion¶
· When fusion is the method of treatment it often requires the use of some form of internal fixation.
· The fusion treatment codes in the system include the use of screws, rods, wire cage etc.
· In relation to a spinal fusion it is common to see fixation devices such as cage implants and rods (Isola rods, Harrington rods, TSHR rods). These are not coded separately; they are included in the treatment of the fusion
Bone Grafts¶
· Commonly seen in conjunction with fusion or arthrodesis
· There are several different types of bone grafts :
· Allograft or Allogeneic Graft - generally when the bone comes from a bone bank or cadaver
· The fusion treatment code in the system covers the use of a bone graft
· No separate coding is required to cover the bone graft
· Autograft or Autologous Graft - when the bone is harvested from the patient, most often from the iliac crest of the pelvis
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This should be coded as a separate treatment as this does induce additional pain and suffering as it requires a separate surgical incision.
- The code to use is 0QB20ZZ.D2 Excision of bone for graft from donor site of iliac crest
· Genetically Produced Bone Protein - a protein that stimulates bone cells and helps the body produce more bone, may be referred to as BMP or rhBMP-2
· If this type of bone graft is used, it is included with the use of the fusion treatment codes in the system
· No separate coding is required
IM Nailing¶
· Intramedullary (IM) nail or rod is used to realign and stabilize a fractured bone. This treatment is most commonly associated with long bones, such as the femur or tibia
· Usually, the IM nail/rod is inserted percutaneously (i.e. through the skin) away from the actual fracture. Thus the reduction of the fracture is achieved without any surgical incision at the actual fracture site and therefore considered to be a closed reduction
· When the procedure is done percutaneously , it is considered in the system as a ‘closed reduction with internal fixation’
· Using freeform search enter ‘closed reduction’ and the body part, select Treatment and Search
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Fracture Fragments¶
· Fracture fragments are not entered into the system
· If fracture fragments are removed during an open reduction, this is part of the procedure
· If an issue arises with fragments after initial treatment they may be referred to as ‘loose bodies’
· If a ‘loose body’ is diagnosed this can be entered in the system
· Using freeform search, enter ‘loose body’ and the body part, select Injury and Search
Multiple Distinct Fractures¶
· When two distinct fractures occur to the same bone, both fractures should be entered as well as their treatment
Pilon Fracture¶
· Pilon fracture typically refers to a comminuted displaced intra-articular distal tibia fracture
o The fracture can sometimes include the fibula
o The fracture consists of a long oblique fracture extending medial to lateral as well as a fracture extending to the tibiotaler articular surface
o Because of the severity of the fracture and its intra-articular involvement, post-traumatic arthritis is a common result
· In the system, if the Pilon fracture involves the tibia and fibula, then enter a fracture code for each bone (use the shaft codes). If the Pilon fracture involves only the tibia, then enter a fracture code for the tibia (shaft) only.
Subtalar Fracture¶
· This is entered in the system using fracture of the talus
· Closed talus fracture code is 825.21.L/R; Open talus fracture code is 825.31.L/R
· The medical library defines the subtalar fracture as part of the talus
o The talus consists of three parts: a head, neck and a body
o The body of the talus is part that fits into the socket created by the lateral and medial malleoli
o The lower part of the body connects with the calcaneus to form what is known as a subtalar joint
o The talar neck connects with the navicular bone while the head also forms part of the subtalar joint