Understanding ICD-10 and Fracture Descriptors: Classification System for Reporting, Exams of History

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ICD-10 and Fracture Descriptors Tal Laor, MD Department of Radiology Cincinnati Children’s Hospital www.aapc.com economictimes.indiatimes.com • Disclosures: None ICD-10 Fracture Report • Etiology • Encounter (initial, subsequent, sequelae) • Fracture Descriptors – Localization – Category – Pattern – Displacement • Healing status (normal, delayed, non-union, malunion) • Etiology • Encounter (initial, subsequent, sequelae) • Fracture Descriptors – Localization – Category – Pattern – Displacement • Healing status (normal, delayed, non-union, malunion) Clinical History and Procedure Comments ICD-10 Fracture Report • Etiology • Encounter (initial, subsequent, sequelae) • Fracture Descriptors – Localization – Category – Pattern – Displacement • Healing status (normal, delayed, non-union, malunion) Findings ICD-10 Fracture Report Clinical History and Procedure Comments • Understand the impact of what is reported e Understand the impact of what is reported Hi All, I saw a girl today in clinic with a displaced distal radius salter 2 fracture seen in the JED 7 days ago who was sent home ina splint without reduction and told to follow-up with ortho in “one week”. At 7 days out now, it is too late to safely reduce it, especially since it would require a trip to the OR to do so now. No ortho consult was Called in the ED, potentially because the radiology read said “3mm” of displacement, which was measured at the Thurstan Holland fragment, despite more than 50% dorsal translation of the epiphysis and at least 15 degrees of angulation. She will remodel but she has a noticeable clinical deformity that will persist for some time. HE an you touch base with the HNMED folks about sending out displaced physeal fractures without calling us? Tal, can we revisit the fracture descriptors with regards to physeal injuries? Thanks,  Fracture Category and Pattern Plastic Deformation • Some bones are bowed normally, so prefer term “plastic deformation” • No fracture line en.wikipedia.org Plastic Deformation Follow-up • Some bones are bowed normally, so prefer term “plastic deformation” • No fracture line • +/- periosteal new bone on f/u en.wikipedia.org Diaphysis Metaphysis (rare) Metadiaphysis (most common) Buckle Fracture • Unicortical failure on the compression side, without cortical break • Metadiaphyseal location • Zone of normal bone between fracture and physis Torus • “Circumferential” cortical bulge –(e.g. inner tube, doughnut, bagel) • Doesn’t really happen in bones • Term no longer used in Orthopedics http://www.daviddarling.info/ Other Incomplete Fractures • Unicortical failure on the tension side = greenstick fracture Greenstick break on tension side Other Incomplete Fractures • Unicortical failure on the tension side = greenstick fracture • If not on tension side = “incomplete fracture with cortical disruption” Greenstick “Incomplete fracture with cortical disruption” break on tension side break on compression side Incomplete Fracture with Cortical Disruption “a broken buckle fracture” Not a buckle (or other incomplete) fracture! Transverse, Oblique, Spiral Normal Type 1 Type 2 Type 3 Type 4 * ** Physeal (Salter Harris Fractures) Thurstan Holland fragment e m en.wikipedia.org Salter Harris Type II d o rs al d o rs al www.car-brand-names.com Physeal Fractures: Part 2. Two Previously Unclassified Types Hamilet A. Peterson, M.D., M.S. Department af Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, U.S.A. Journal of Pediatric Orthopedics, 1994. 14: 431-438 mmmary: This article describes two physeal fractures t previously classified. The first is a fracture com- pletely across the metaphysis with extension to the phy- a. There is usually no extension of the fracture along the physis, as is seen with the Salter—-Harris type II fractures. itis a common fracture, occurring in 15.59 of the Olm- i County study. The second previous unclassified fracture is one in which a portion of the physis is missing. This is always an open fracture, and, thus, always re- quires initial surgery. It almost always develops prema- ture physeal closure and almost always requires late re- constructive surgery. Key Words: Metaphyseal-to- physeal fraciure—Physeal fracture with part missing. d o rs al d o rs al d o rs al d o rs al d o rs al d o rs al Bucket handle or Corner Fracture (Metaphyseal Fracture) metadiaphysis metaphysis Modified from Tsai A, et al. Pediatr Radiol 2014. 44:124-140. Classic Metaphyseal Lesion (CML) Corner Fracture Bucket Handle Fracture= Pathologic Fracture Stress Fracture versus “Stress Response/Reaction” • No fracture line • Area of sclerosis • Fine line between healing stress fracture and stress response (both chronic) • Versus sclerosis as a response to acute injury Displacement Type • Translation –Sideways –Shortening/distraction • Angulation –Apex location –(Rotation) Displacement Type • Translation –Sideways –Shortening/distraction • Angulation –Apex location –(Rotation) Translation Direction and Magnitude • Direction: – Medial/lateral, dorsal/volar, plantar/palmar, anterior/posterior, radial/ulnar, etc. – Do NOT use medial/lateral for wrist and hand • Magnitude: – Extra-articular: in percent (%) – Intra-articular: in mm • Must comment on joint alignment (concentric, subluxated, dislocated) • Extra-articular, so use % • Radius: 95% translation in ulnar direction • Ulna: 40% translation in ulnar direction Translation Direction and Magnitude • Intra-articular, so use mm • Distraction and step-off Translation Direction and Magnitude • Intra-articular, so use mm • Distraction and step-off Translation Direction and Magnitude 2 mm lateral translation, no step off, concentric joint 3 mm dorsal translation < 1 mm lateral translation Translation Joint concentricity Translation Joint concentricity 3 mm dorsal translation, Concentric joint alignment < 1 mm lateral translation, Concentric joint alignment Translation Joint concentricity 3 mm dorsal translation, Concentric joint alignment < 1 mm lateral translation, Concentric joint alignment Shortening/Distraction (Overlap or Separation) • Direction – Shortening or distraction • Magnitude – in mm Angulation Direction and Magnitude • Apex location (e.g. anterior/posterior, radial/ulnar, superior/inferior), varus/valgus, etc. • In degrees (⁰) • Do NOT use mild, moderate, severe, minimal, substantial, etc. Salter Harris Fractures • Displacement • Use the epiphysis for angulation • Transverse axis of epiphysis should be 90⁰ to shaft Salter Harris Fractures • Displacement • Use the epiphysis for angulation • Transverse axis of epiphysis should be 90⁰ to shaft 30 degrees apex volar angulation Salter Harris Fractures • Displacement • Use the epiphysis for angulation • Transverse axis of epiphysis should be 90⁰ to shaft • Use the epiphysis for translation • Do not use the Thurston Holland fragment for quantification Ortho wrote: “Also note the clinical deformity! The overall contour will be deceptively normal due to swelling, but when the cast comes off, this is a crooked wrist.” • Can be difficult to determine radiographically • Is often used interchangeably with angulation Rotation • Can be difficult to determine radiographically • Is often used interchangeably with angulation • “Lateral condylar fracture with 45 degrees varus rotation” (or angulation) Rotation Healing Status Healing • No callus or periosteal new bone (very early) Healing • Early signs of healing (callus, periosteal new bone, + fracture line)