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Appendix

doi: 10.1097/BOT.0000000000001055
Supplement Article

In this section, guides to help the coder classify fractures are provided.

Within each bone segment, references are made to this section if specific definitions or suggestions for coding are required.

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Radius and Ulna

To facilitate the coding of radius and ulna fractures, they are coded by the individual bone. The following guidelines are suggested:

  • The location of the end segment requires that the square has as its side dimension the widest part of the end segment, which includes both the radius and ulna (Fig 1).
  • Each fracture is coded, stored, and searched for separately ie, as two codes.
  • Galeazzi and Monteggia fracture codes:
  • Galeazzi and Monteggia fracture patterns consist of a shaft fracture with associated joint dislocation or injury. The code for the injury complex is the radius or ulna fracture code with a qualifier of g for Galeazzi representing disruption of the distal radioulnar joint (DRUJ) and m for Monteggia representing disruption of the proximal radioulnar joint (PRUJ). This qualification is placed at the end of the code in round brackets (__).
  • If the coder feels that it is necessary to code for joint dislocation and its direction, the dislocation code from the universal modifiers is added within square brackets [5_] following the round brackets (Fig 2).
Fig 1

Fig 1

Fig 2

Fig 2

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Femur

It is recognized that there is an ongoing controversy concerning the proper terminology for trochanteric fractures (James Krieg, personal communication, October 2016; Christopher Colton, personal communication, May 2017).1–5 The CCF and past compendiums have established that the term pertrochanteric means through the trochanters as shown in group A1 and group A2. Intertrochanteric means between trochanters as represented in group A3. This term should be preferred to reverse oblique. To remain consistent, this revision maintains these definitions and recommends their use as noted above.

The coding system separates the pertrochanteric fractures into two groups (A1 and A2) based on the amount of fragmentation in the trochanteric region. The differentiation between groups is defined by the lateral wall height (d) of the greater trochanter (Fig 3). Lateral wall height or thickness is defined as the distance in millimeters (mm) from a reference point 3 cm below the innominate tubercle of the greater trochanter angled 135° upward to the fracture line on the anteroposterior x-ray. The thickness (d) must be less than 20.5 mm for the fracture to be considered an A2 fracture. It is recommended that the measurement for the lateral wall be taken using the traction view with the leg in neutral rotation.6 , 7

Fig 3

Fig 3

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Fibula

The lower leg, like the forearm is a two-bone system. In previous editions of the compendium, the fibula had its classification linked to the tibia code. To provide more flexibility in coding, a fibula code based on the CCF principles has been added. The use of an F is required to designate the fibula. The F follows the 4 which represents the anatomical area of the lower leg or tibia/fibula. If a fibula fracture is part of ankle fracture it is coded as a 44. The fibula code is used only for fibula fractures not associated with ankle fractures.

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Proximal tibia (tibial plateau)

A more detailed description of the morphology and location of the proximal end segment articular fracture lines has been suggested (Maurico Kfuri, personal communication, July 24, 2017). Kfuri and Schatzker have divided the proximal tibial articular surface into quadrants. The anterior and posterior segments are created by a virtual line from the anterior aspect of the fibular head (FH) to the posterior edge of the medial collateral ligament (MCL), which coincides with the medial tibial crest. The medial and lateral sides are determined by a line from the medial side of the anterior tibial tubercle to the posterior cortex and runs between the tibial spines. Using these two virtual planes, four quadrants of the tibial surface are defined: AL (anterolateral zone), PL (posterolateral zone), PM (posteromedial zone), AM (anteromedial zone) (Fig 4).

Fig 4

Fig 4

The following rules apply to this detailed addition of the proximal tibia:

  1. Using the CT scan, the quadrants are defined on the axial plane of the proximal tibia surface.
  2. The fracture lines are followed until they emerge on the metaphyseal cortex. This will dictate the plane of the main fracture line.
  3. If the main fracture plane emerges posterior to the virtual equator it is a P. If the main fracture plane emerges anterior to the virtual equator it is an A.
  4. If the majority of the fragmentation or articular surface occurs either medially or laterally it is correlated with the cortical exit and coded using the qualifications for alphanumeric codes: AM for anteromedial, AL for anterolateral, PM for posterior medial or PL for posterior lateral.
  5. These are usually applied to bicondylar fractures but may also be used for unilateral plateau fractures.
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Malleolar segment

An isolated medial malleolar fracture is classified as a tibial distal end segment partial articular fracture, 43B1.2(6).

If the medial malleolar fracture is associated with a lateral side ankle injury, it is classified as a malleolar fracture, 44.

A fracture of the posterior articular margin (Volkmann) without a lesion of the fibula is considered a fracture of the distal end segment of the tibia ie, 43B1.1(6).

If a fibula fracture is part of ankle fracture it is coded as a 44. The fibula code is used only for fibula fractures not associated with ankle fractures.

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Scapula

The four quadrants (Fig 5) are defined by the equatorial line and the intertubercular line (maximum glenoid meridian) running from the supraglenoid tubercle to the infraglenoid tubercle.

Fig 5

Fig 5

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Dislocations

The coding is as follows:shoulder girdle where all dislocations are 10.

  • The first number represents the distal bone of the dislocated joint
  • The second number is 0 for dislocation (with the exception of the
  • The third letter (A, B, C, D, or E) is utilized when there are more than two bone articulations in the anatomical region.
  • The direction of the dislocation is coded using the universal modifiers for dislocation direction [5_]. By convention, the direction of the dislocation is defined as the position of the distal bone relative to its anatomical position.
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17 Periprosthetic fracture—arthroplasty related

The importance of the Unified Classification of Periprosthetic Fractures (UCPF) is its descriptive nature of the prosthesis-bone interface and relationship of the fracture to the prosthesis. Consequently, the use of the classification demands that the UCPF be used as the description of the fracture in the clinical scenario. To standardize the coding process for the compendium, a modification of the UCPF was required. In collaboration with Duncan and Haddad, an agreement was reached to have the bone fracture code described first followed by the UCPF code enclosed in square brackets, thereby utilizing it as a universal modifier.

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References

1. Stimson LA. A Practical Treatise on Fractures and Dislocations.8th ed. New York and Philadelphia: Lea & Febiger; 1917:394.
2. Watson-Jones R. Fractures and Other Bone and Joint Injuries: Second Edition. Edinburgh: E&S Livingstone; 1941:4934.
3. Bohler L. The Treatment of Fractures. Vol. 2. New York: Grune and Stratton; 1957:1370–1376.
4. Wilson PD, Cochrane WA. Fractures and Dislocations. Philadelphia London: JB Lippincott; 1925: 513–519.
5. Tang HC, Chen IJ, Yeh YC, et al. Correlation of parameters on preoperative CT images with intra-articular soft-tissue injuries in acute tibial plateau fractures: A review of 132 patients receiving ARIF. Injury. 2017 Mar;48(3):745–750.
6. Palm H, Jacobsen S, Sonne-Holm S, et al. Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: An important predictor of a reoperation. J Bone Joint Surg Am.2007;89:470–475.
7. Hsu CE, Shih CM, Wang CC, et al. Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures. Bone Joint J. 2013 Aug;95-b(8):1134–1138.
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