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Current RMA Instruments
|Reasonable Hypothesis SOP||94 of 2015|
|Balance of Probabilities SOP||95 of 2015|
Changes from previous Instruments
ICD-10-AM codes S02, S12, S22, S32, S42, S52, S62, S72, S82, S92
This SOP covers:
- Traumatic fractures, from both:
- acute trauma - an acute injury event usually involving significant force; and
- repetitive trauma - stress (or fatigue) fractures from cumulative loading forces;
- Pathological fractures (minimal trauma fractures) - underlying bone pathology contributes to a fracture that may occur with normal or minimal forces. Examples of pathological conditions associated with these types of fractures are Paget’s disease; osteoporosis; osteomalacia; osteonecrosis; osteomyelitis; bone neoplasia; and osteogenesis imperfecta.
Confirming the diagnosis
Acute traumatic fracture may be evident clinically but will normally be confirmed by radiological imaging.
A stress fracture will require imaging evidence to confirm (e.g. MRI, bone scan).
A pathological fracture will be confirmed by imaging which will also likely indicate the presence of any underlying bone disease.
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 identified by imaging.
- 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
This is somewhat different depending on the type of fracture:
- For acute 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 fracture. Note that the clinical onset of the underlying disease is different.
The usual result from a traumatic fracture is for healing to occur and a good functional outcome to be achieved following appropriate clinical management. Such management will involve reduction (setting/fixation) and immobilisation for an acute traumatic fracture and avoiding/reducing the causative activity for stress fracture. Worsening in the form on non-union or malunion may result from inadequate or inappropriate treatment. Delayed union will generally not represent (permanent or enduring) clinical worsening.
Some traumatic fractures, by their nature/geometry, are prone to poor outcomes even with appropriate care. Where that is the case, the initial fracture is the cause of the poor outcome and worsening is unlikley to be a relevant consideration.
Further trauma to an unhealed fracture may result in a worsening of the fracture, either by making the fracture more extensive or impeding healing leading to a worse final outcome.
A refracture of a well healed traumatic fracture is a new event, not a worsening of the original fracture.
Development of a complication such as osteonecrosis, osteomyelitis or osteoarthritis at the site of a traumatic fracture is an onset of a new disease (covered by a separate SOP for each of those examples), not a worsening of a fracture.
Pathological fractures tend to heal poorly and commonly require fixation. Specialist advice is likely to be needed if clinical worsening is being considered.
Comments on SOP factors
Note that the SOP factors listed for minimal trauma only, 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.