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Fracture N001

Document
Last amended 
3 April 2016
Current RMA Instruments:
Reasonable Hypothesis SOP
94 of 2015
Balance of Probabilities SOP
95 of 2015
Changes from Previous Instruments:

SOP Bulletin 185

ICD coding:

Bone which is fractured

Fracture code

Skull

(ICD-9 800; ICD-10 S02.0)

Skull – vault

(ICD-9 800; ICD-10 S02.0)

Skull - base

(ICD-9 801; ICD-10 S02.1)

Maxilla

(ICD-9 802; ICD-10 S02.4)

Nose

(ICD-9 802.0; ICD-10 S02.2)

Mandible

(ICD-9 802.2; ICD-10 S02.6)

 

 

Cervical spine

(ICD-9 805.0; ICD-10 S12)

Thoracic or dorsal spine

(ICD-9 805.2; ICD-10 S22.0)

Lumbar spine

(ICD-9 805.4; ICD-10 S32.0)

Sacrum

(ICD-9 805.6; ICD-10 S32.1)

Coccyx

(ICD-9 805.6; ICD-10 S32.2)

 

 

Rib

(ICD-9 807.0; ICD-10 S22.3)

Sternum

(ICD-9 807.2; ICD-10 S22.2)

Pelvis

(ICD-9 808; ICD-10 S32.83)

Pelvis – Ilium

(ICD-9 808.41; ICD-10 S32.3)

Pelvis – Ischium

(ICD-9 808.42; ICD-10 S32.81)

Pelvis - Pubis

(ICD-9 808.2; ICD-10 S32.5)

 

 

Clavicle

(ICD-9 810; ICD-10 S42.0)

Scapula

(ICD-9 811; ICD-10 S42.1)

Humerus

(ICD-9 812; ICD-10 S42.2)

Radius

(ICD-9 813; ICD-10 S52.3)

Ulna

(ICD-9 813; ICD-10 S52.2)

Carpal bones

(ICD-9 814; ICD-10 S62.1)

Scaphoid

(ICD-9 814.01; ICD-10 S62.0)

Metacarpal

(ICD-9 815; ICD-10 S62.2)

Thumb - Phalange

(ICD-9 816; ICD-10 S62.5)

Fingers - Phalange

(ICD-9 816; ICD-10 S62.6)

 

 

Femur

(ICD-9 820; ICD-10 S72.9)

Patella

(ICD-9 822; ICD-10 S82.0)

Tibia

(ICD-9 823; ICD-10 S82.2)

Fibula

(ICD-9 823; ICD-10 S82.4)

Ankle

(ICD-9 824; ICD-10 S82.88)

Calcaneus

(ICD-9 825.0; ICD-10 S92.0)

Tarsal bones

(ICD-9 825; ICD-10 S92.2)

Talus

(ICD-9 825.21; ICD-10 S92.1)

Metatarsal

(ICD-9 825.25; ICD-10 S92.3)

Hallux - Phalange

(ICD-9 826; ICD-10 S92.4)

Toe - Phalange

(ICD-9 826; ICD-10 S92.5)

 

Brief description:

This SOP covers two different pathologies:

  • Traumatic fracture – which is a normal bone being broken by abnormal applied forces. Hence this is an injury. Note that the applied force is significant and not trivial or minimal. This significant force can:
    • Be of sufficient force to fracture the bone immediately, OR
    • Be of lesser force (but still significant) and applied repetitively in a loading cycle sufficient to cause a fatigue fracture, also called stress fracture.  
  • Atraumatic fracture or pathological fracture – which is an abnormal bone being broken by normal applied forces (i.e. minimal trauma). This is a disease. Examples explicitly noted in the SOP are Paget’s disease; osteoporosis; osteomalacia; osteonecrosis; osteomyelitis; bone neoplasia; osteogenesis imperfecta. The Repatriation Medical Authority has designated these pathological fractures as ‘minimal trauma fracture’.
Confirming the diagnosis:

To confirm the diagnosis there needs to be imaging evidence of a fracture, on the basis of a plain xray, CT scan, MRI scan or radionucleotide bone scan.

A stress fracture cannot be based on clinical findings but must be confirmed by radionucleotide bone scan or by callous development on subsequent xray imaging.

The imaging should also report on whether the fracture was associated with underlying bone disease, which may indicate that this was a pathological fracture or a minimal trauma fracture.

The relevant medical specialist is an orthopaedic surgeon.

Additional diagnoses covered by these SOPs
  • Stress fracture – This fracture is where there is no displacement of the bone fragments, and the fracture is detected by noting a hot spot on a radionucleotide bone scan.
  • Comminuted fracture – This is a fracture with multiple small fragments.
  • Open fracture – This is where the bone penetrates the skin.
  • Closed fracture – This is were there is no bone penetrating the skin.
  • Pathological fracture – this is a fracture due to the underlying bone disease occurring with minimal or nil trauma.
  • Minimal trauma fracture – this is a pathological fracture with minimal or nil trauma due to the underlying bone disease.
Conditions not covered by these SOPs
  • Fractures of the teeth* - Loss of teeth. (Note that teeth are not bone).
  • Spondylolysis* - Spondylolisthesis and spondylolysis
  • Pars defect* - Spondylolisthesis and spondylolysis
  • Pars interarticularis defect or fracture* - Spondylolisthesis and spondylolysis
  • Stress reaction – This is not a disease or injury but a physiological sign.
  • Bone bruise# – A bone bruise is a new entity reported as a result of higher resolution imaging in CT and MRI scans and is part of the injury spectrum. The aetiological factors in the external bruise SOP are recommended even though the SOP itself is not directly applicable.

* another SOP applies  - the SOP has the same name unless otherwise specified

# non-SOP condition

Clinical onset

This is somewhat different depending on the type of fracture:

  • For traumatic fracture – Since this is an acute injury, the clinical onset is the date of injury or the application of the significant force with immediate symptoms.
  • For stress fracture – this is the date of the first symptoms which subsequently continued without break and were then confirmed to be a stress fracture.
  • For a pathological or minimal trauma fracture – this is the date of the first symptoms which subsequently continued without break and were then confirmed to be a stress fracture. Note that the clinical onset of the underlying disease is different.
Clinical worsening

It is difficult to conceive how a fracture could become clinically worse, given that the definition of a fracture is an ‘acquired break or rupture of bone’. A partial sprain of a ligament may be clinically worsened by becoming a complete sprain, but a bone is already by its definition a complete break of the bone.

A possibility is that the fracture is worsened by being converted into a compound fracture from a closed fracture. That is the broken bone was pushed through the skin.

Another possibility is that a fracture such as a scaphoid fracture of the wrist was not immobilised and hence suffered with osteonecrosis.

An additional fracturing of the initial fracture would not be a worsening of the fracture but a fresh fracture.

The natural history of a fracture is to heal, so it is possible that a fracture could worsen by not healing at all in the form of a non-union, or pseudoathrosis.

A fracture may be worsened during its initial healing stage if the fibrous or bony callous around the fracture was disrupted by a further trauma.

A fracture malunion may or may not represent a clinical worsening. A poorly aligned fracture or a shortened fracture is not necessarily a clinical worsening of the fracture since it may result from the poor fracture geometry resulting from the original fracturing. For example a comminuted fracture is susceptible to shortening, as is a spiral fracture. Similarly a fracture through a joint has a poor prognosis. Hence even though medical personnel may strive to optimise a fracture healing, the poor state of the original fracture geometry at the time of injury may be the principal cause of the poor fracture healing with minimal contribution from other factors. Accordingly, the fracture had a very poor prognosis at clinical onset (that is, it was never going to heal well), so it could not clinically worsen over time.   Hence it was already at its worst at the time of the clinical onset.

Comments on SOP factors

Note that the set of factors collected under the minimal trauma only label, are only applicable when fracture has occurred in the absence of significant trauma.  These factors do not apply for stress fractures.  They can apply when there is an underlying bone disease (e.g. Paget's disease, osteomalacia, etc.) that cannot itself be related to service.