Fracture N001

Current RMA Instruments

Changes from previous Instruments

ICD coding

ICD-10-AM codes S02, S12, S22, S32, S42, S52, S62, S72, S82, S92, T79.1, R57.8, S86.9, T14.20, M84.19, M84.09, T90.2, T91.1, T92.1, T93.1, T93.2

Brief description

Fracture is defined as an acquired break of bone as a result of an applied force that ordinarily would cause bone breakage in a healthy bone.

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 

Confirming the diagnosis

Acute traumatic fracture may be evident clinically but will normally be confirmed by radiological imaging.

A stress fracture will usually require imaging evidence to confirm (e.g. MRI, bone scan).

Fracture can generally be diagnosed by a general practitioner. Assessment by an orthopaedic surgeon may be required in complex cases.  

Additional diagnoses covered by these SOPs

• Stress fracture-An undisplaced bone break from repeated stresses (none individually causal) in someone without known underlying bone pathology. 
• Comminuted fracture-This is a fracture with multiple small fragments.
• Open fracture/Compound fracture-This is where the bone penetrates the skin.
• Closed fracture-This is where there is no bone penetrating the skin.
• Avulsion fracture-Bone fragment is pulled away from the rest of the bone. 
• Crush fracture/Compression fracture-SOP covers traumatic spinal compression fracture secondary to axial loading and flexion. 
• Burst fracture-This is a type of spinal compression fracture related to high energy axial loading and flexion causing the bone to enter the spinal canal.
• Blowout fracture-This is a fracture caused by direct blow to the orbit, commonly resulting in the herniation of the orbital contents. 
• Torsion/Spiral fracture-This is a complete fracture caused by a rotational or twisting force. 
• Growth Plate fracture
• Fracture of bone contiguous with an orthopaedic implant 
• Acute vascular shock, acute compartment syndrome, or fat embolism resulting from the fractured bone
• Periosteal, muscular, fascial, skin, nerve or vascular damage directly caused by the displaced fractured bone
• Wound infection as a result of penetration of the skin by bony fracture fragments (compound fracture)

Conditions not covered by these SOPs

• Pathological fracture * -Pathological fracture SOP (underlying bone pathology contributes to a fracture that may occur with normal or minimal forces)
• Fractures of the teeth * - Loss of teeth SOP (note that teeth are not bone)
• Spondylolysis *- Spondylolisthesis and spondylolysis SOP
• Pars defect * - Spondylolisthesis and spondylolysis SOP
• Pars interarticularis defect or fracture*-Spondylolisthesis and spondylolysis SOP
• Fracture of cartilage*- Acute articular cartilage tear SOP 
• Osteonecrosis* - Osteonecrosis SOP
• Periostitis*- Medial tibial stress syndrome (Shin splints) SOP 
• Stress fracture of the insufficiency type*-Pathological fracture SOP
• Stress reaction (of bone) # – An imaging finding (from CT, MRI or bone scan). No fracture present (no cortical disruption). Can be diagnosed as non-SOP if symptomatic (causation is as for stress fracture). Otherwise not a disease or injury.
• Bone bruise/Bone contusion # – Bleeding into and swelling of bone due to acute trauma, but without fracture. 
• Fracture of an orthopaedic implant including a screw, nail, fixation plate or prosthesis #

* another SOP applies

^# non-SOP condition

Clinical onset

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.

Clinical worsening

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 (fracture fails to heal) or malunion (fracture heals in an abnormal position) 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 unlikely to be a relevant consideration. 

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.