Fracture Documentation Guidelines

General Identify episode of care

Initial
Subsequent
 With routine fracture healing
 With delayed fracture healing
 With non-union of fracture
Laterality
Sequela of injury
Place of occurrence of injury
Activity of patient at time of injury

Pelvis Identify fracture site/type

Acetabulum
Anterior column (iliopubic)
Anterior wall
Dome
Medial wall
Posterior column (ilioischial)
Posterior wall
Transverse
 Alone ( without associated posterior wall fracture)
 With associated posterior wall fracture
Ilium
Avulsion
Other specified fracture of ilium
Unspecified fracture ilium
Ischium
Avulsion
Other specified fracture of ischium
Unspecified fracture ischium
Pubis
Superior rim
Other specified fracture of pubis
Unspecified fracture of pubis
Multiple fractures of pelvis
With disruption of pelvic circle
 Stable
 Unstable
Without disruption of pelvic circle
Identify fracture status
Displaced
Nondisplaced
Identify laterality – left, right
Identify fracture as closed or open

Humerus, Surgical Identify site/type

Neck Greater tuberosity
Lesser tuberosity

1
 Surgical neck
2-part
3-part
4-part
Unspecified surgical neck fracture
Torus Fracture
Other specified site, which includes
Anatomical neck
Articular head
Identify fracture status
Displaced
Nondisplaced
Identify laterality – left, right
Identify fracture as closed or open

Shaft of Radius Identify type of radial/ulna shaft fracture

and Ulna Bent bone
Comminuted
Galeazzi’s fracture
Greenstick
Oblique
Segmental
Spiral
Transverse
Identify fracture status
Displaced
Nondisplaced
Identify laterality – left, right
Identify fracture
Closed
Open
Gustilo Type I, II or open but not otherwise specified
Gustilo Type IIIA, IIIB, IIIC

Carpal Bones Identify site

Capitate (os magunum)
Hamate (unciform)
Body
Hook process
Lunate
Navicular (scaphoid)
Distal pole
Middle third
Proximal third
Pisiform
Trapezoid (Smaller multangular)
Trapezium (larger multangular)
Triquetrum (cuneiform)
Identify fracture status
Displaced
Nondisplaced

2
 Identify laterality – left, right
Identify fracture as closed or open

Metacarpal Bones Identify metacarpal bones fractured

First metacarpal (thumb)
Other metacarpal bone
Second
Third
Fourth
Fifth
For thumb, identify fracture site/type:
Base
Bennett’s fracture
Rolando’s fracture
Other fracture of base
Neck
Shaft
For other metacarpal bones (second, third, fourth, fifth), identify fracture site
Base
Neck
Shaft
Other fracture
Identify fracture status
Displaced
Nondisplaced
Identify laterality – left, right
Identify fracture as closed or open

Neck of Femur Identify site of femoral fractures

Neck
Base of neck
Epiphysis
Intracapsular (subcapital), unspecified
Midcervical
Head
Articular
Other specified site
Pertrochanteric
Apophyseal
Greater trochanter
Intertrochanteric
Lesser trochanter
Subtrochanteric
Identify fracture status
Displaced
Nondisplaced
Identify laterality – left, right
Identify fracture
Closed
Open
Gustilo Type I, II or open but not otherwise specified

3
 Gustilo Type IIIA, IIIB, IIIC

Tibula and Fibula Identify lower leg bone

Tibia
Fibula
Identify site/type of fracture
Tibia upper end
Condylar
 Lateral
 Medial
 Bicondylar (includes tibial plateau)
Torus
Tuberosity
Other specified
Tibial shaft
Comminuted
Oblique
Segmental
Spiral
Transverse
Fibular shaft
Comminuted
Oblique
Segmental
Spiral
Transverse
Identify fracture status
Displaced
Nondisplaced
Identify laterality – left, right
Identify fracture
Closed
Open
Gustilo Type I, II or open but not otherwise specified
Gustilo Type IIIA, IIIB, IIIC

Physeal Fracture Identify bone

Femur
Fibula
Humerus
Radius
Tibia
Ulna
Identify site
Lower end physeal fracture
Upper end physeal fracture
Identify Salter-Harris classification
Salter-Harris Type I
Salter-Harris Type II
Salter-Harris Type III
Salter-Harris Type IV

4
 Other physeal fracture
Identify fracture status
Displaced
Nondisplaced
Identify laterality – left, right

Cervical Vertebra Identify type/site

First cervical
Stable burst
Unstable burst
Posterior arch
Lateral mass fracture
Second cervical
Type II dens fracture
 Anterior displaced
 Posterior displaced
 Nondisplaced
Other dens fracture
Type III traumatic spondylolisthesis
Other traumatic spondylolisthesis
Third – Seventh vertebra
Type III traumatic spondylolisthesis
Other traumatic spondylolisthesis
Unspecified spondylolisthesis fracture
Identify fracture status
Displaced
Nondisplaced
Identify Spinal cord injury
Anterior cord syndrome
Brown-Sequard syndrome
Central cord syndrome
Complete lesion of cord
Concussion/edema
Identify highest level of cervical spinal cord injury:
C1-C8

Thoracic Vertebra Identify vertebral level

First
Second
Third
Fourth
T5-T6
T7-T8
T9-T10
T11-T12
Identify type of fracture
Stable burst
Unstable burst
Wedge compression

5
Lumbar Vertebra Identify vertebral level
First
Second
Third
Fourth
Fifth
Identify type of fracture
Stable burst
Unstable burst
Wedge compression

Sacrum Identify Zone

Zone I: injuries are entirely lateral to the neuroforamina
Zone II: injuries involve the neuroforamina but not the spinal canal
Zone III: injuries extend into the spinal canal with primary or associated fracture
lines
Identify Type
Type 1: transverse flexion fracture of sacrum without displacement
Type 2: transverse flexion fracture of sacrum posterior displacement
Type 3: transverse extension fracture of sacrum anterior displacement
Type 4: transverse segmental communition of upper sacrum
Identify fracture status
Displaced
Nondisplaced

Sternum Identify site/type

Manubrium
Body of sternum
Sternal manubrial dissociation
Xiphoid process

Ribs Identify type

Single rib
Multiple ribs
Identify laterality – left, right, bilateral

Skull Identify skull fracture site

Vault of Skull
Frontal bone
Parietal bone
Base of Skull
Anterior fossa
Ethmoid sinus
Frontal sinus
Middle fossa
Occipital bone
Orbital roof
Posterior fossa
Sphenoid bone
Temporal bone

6
Identify nature of any intracranial injury
Concussion
Cerebral edema, which includes
Diffuse edema
Focal edema
Contusion/laceration
Brainstem
Cerebellum
Cerebrum
 Right cerebrum
 Left cerebrum
Diffuse traumatic brain injury
Focal traumatic brain injury
Hemorrhage
Intracranial
 Brainstem
 Cerebellum
 Cerebrum, left
 Cerebrum, right
Epidural
Subarachnoid
Subdural
Other specified intracranial injury
Identify loss of consciousness
No loss of consciousness
30 minutes or less
31 minutes to 59 minutes
1 hour to 5 hours 59 minutes
6 hours to 24 hours
Greater than 24 hours
With return to pre-existing conscious level
Without return to pre-existing conscious level
Any duration with death prior to regaining consciousness
Death due to brain injury
Death due to other cause
Identify Fracture as Closed or Open