| ICD-9-CM: |
| 733.1 - | Pathologic Fracture; Spontaneous Fracture |
| 767.2 - | Birth Trauma; Fracture of Clavicle |
| 800 - | Fracture of Vault of Skull, Includes Parietal and Frontal Bone |
| 801 - | Fracture of Base of Skull; Anterior; Middle; Posterior; Occiput Bone; Orbital Roof; Ethmoid; Frontal; Sphenoid Bone; Temporal Bone |
| 802 - | Fracture, Face Bones |
| 802.0 - | Fracture, Nasal Bones, Closed |
| 802.1 - | Fracture, Nasal Bones, Open |
| 802.2 - | Fracture of Mandible, Closed, Inferior Maxilla; Lower Jaw (Bone) |
| 803 - | Other and Unqualified Skull Fractures |
| 804 - | Multiple Fractures involving Skull or Face with Other Bones |
| 805 - | Fracture of Vertebral Column without Mention of Spinal Cord Injury |
| 806 - | Fracture of Vertebral Column with Spinal Cord Injury |
| 807.0 - | Closed Fracture of Rib(s) |
| 807.1 - | Open Fracture of Rib(s) |
| 808 - | Fracture, Pelvis |
| 810 - | Fracture, Clavicle |
| 811 - | Fracture, Scapula (Shoulder Blades) |
| 812 - | Fracture of Humerus |
| 812.0 - | Closed Fracture of Upper End of Humerus |
| 812.1 - | Open Fracture of Upper End of Humerus |
| 812.2 - | Closed Fracture of Unspecified Part of Humerus |
| 812.3 - | Open Fracture of Shaft or Unspecified Part of Humerus |
| 812.4 - | Closed Fracture of Humerus, Distal End; Closed Fracture of Elbow |
| 812.5 - | Open Fracture of Lower End of Humerus |
| 813 - | Fracture of Radius and Ulna |
| 813.0 - | Fracture of Upper End of Radius and Ulna, Closed; Proximal End |
| 813.1 - | Open Fracture of Radius and Ulna, Upper End |
| 813.2 - | Closed Fracture of Shaft of Radius and Ulna |
| 813.3 - | Fracture, Radius and Ulna, Shaft, Open |
| 813.4 - | Closed Fracture of Lower End of Forearm |
| 813.5 - | Fracture, Lower End of Forearm, Open |
| 813.8 - | Closed Fracture of Unspecified Part of Radius with Ulna |
| 813.9 - | Open Fracture of Unspecified Part of Radius with Ulna |
| 814 - | Fracture of Carpal Bone(s) |
| 815 - | Fracture of Metacarpal Bone(s) |
| 816 - | Fracture, Phalanges of Hand (One or More) |
| 820 - | Fracture of Neck of Femur |
| 821 - | Fracture of Femur, Other and Unspecified Parts |
| 822.0 - | Closed Fracture of Patella |
| 822.1 - | Open Fracture of Patella |
| 823.0 - | Closed Fracture of Upper End of Tibia or Fibula |
| 823.1 - | Open Fracture of Upper End of Tibia or Fibula |
| 823.2 - | Closed Fracture of Shaft of Tibia or Fibula |
| 823.3 - | Open Fracture of Shaft of Tibia or Fibula |
| 823.8 - | Closed Fracture of Tibia and Fibula, Unspecified Part |
| 823.9 - | Open Fracture of Tibia and Fibula, Unspecified Part |
| 824 - | Fracture of Ankle |
| 824.0 - | Closed Fracture of Medial Malleolus: Closed Fracture of Tibia Involving Ankle, Malleolus |
| 824.1 - | Open Fracture of Medial Malleolus |
| 824.2 - | Closed Fracture of Lateral Malleolus |
| 824.3 - | Open Fracture of Lateral Malleolus |
| 824.4 - | Closed Bimalleolar Fracture; Potts Fracture |
| 824.5 - | Open Bimalleolar Fracture |
| 824.6 - | Closed Trimalleolar Fracture |
| 824.7 - | Open Trimalleolar Fracture |
| 825 - | Fracture of Tarsal and Metatarsal Bones, One or More |
| 825.0 - | Closed Fracture of Calcaneus (Heel Bone) |
| 825.1 - | Open Fracture of Calcaneus (Heel Bone) |
| 826.0 - | Closed Fracture of Phalanges of Foot, One or More |
| 826.1 - | Open Fracture of Phalanges of Foot, One or More |
| | | |  | | © Reed Group | | |
Fractures are a structural break and disruption in bones of any size or shape. A fracture occurs when force is applied to a bone in an amount greater than it can support. The amount of force required to cause a fracture depends on the composition and strength of the bone. The force may be a direct force as from a blow, a twisting force, or repeated pounding on the same bone. Fractures can also occur because of diseases that affect the strength of the bone or the protective structures around it (pathological fractures, fractures into bone tumors). Repeated impact and stress on an area of bone can potentially cause a break referred to as a stress fracture. For example, marching or running can cause repeated stress on a bone and potentially result in a stress fracture.
There are many types of fractures, which are defined by the number of bone fragments affected and their position. All fractures are described in terms of five different categories: location of the bone in the body (anatomic location), direction of the fracture lines (transverse, oblique, spiral, comminuted, or impacted), the relation of the bone pieces to each other (alignment and apposition), the stability of the fracture, and the amount of soft tissue damage around the fracture (simple or closed, compound or open, complicated, uncomplicated). Muscles attached to the bones involved often pull the fracture fragments out of position, especially if the muscles go into spasm. This can change the status of a fracture from one where the fragments have not shifted out of position (nondisplaced) to one where they have become displaced.
Risk: Individuals of an advanced age, individuals exposed to falls and/or objects falling on them, as well as those involved in high-risk activities performed with high-impact or at high-velocity are at increased risk for fractures. |
Source: Medical Disability Advisor
| History: Fractures are either the result of a traumatic event or repeated stress to an area of the body. In cases of trauma related fractures, individuals may describe an injury, such as a fall or an object falling on them. In cases of stress fractures, the individual may not remember a specific injury, but there is usually a history of recent activity to which the individual is not accustomed. Individuals may have obviously misshapen (deformed) bones, swelling, pain and/or lack of feeling (decreased sensation) near the area of a fracture. The ability to move and use an injured body part does not exclude the possibility of a fracture. It is important to obtain a thorough history, including questioning about previous injuries. Physical exam: Visual examination may be diagnostic in cases where the deformity is obvious. Touching the area (palpation) reveals pain or tenderness over the area. There may be decreased sensation beyond the fracture. Swelling and bruising (ecchymosis) is usually present. Joint looseness (laxity) and changes in range of motion may be evident. Tests: Plain x-rays are used to determine the presence of a fracture, the severity of the fracture, and the position of the fragments. X-rays must include the joint above and below the injury site. Subtle (occult) fractures may not be visible on x-ray exam for up to 2 weeks after they occur. CT scans and/or MRI may be needed to further define the fracture and its effect on surrounding joints. EMG and angiography may be required to evaluate damage to nerves and vessels. A bone scan may show a subtle fracture, such as a stress fracture not easily recognized on plain x-rays. |
Source: Medical Disability Advisor
| If the bone fragment ends are in adequate position for healing to occur, protective rest (immobilization) may be all that is needed for treatment of the fracture. The device used for immobilization may range from a sling, to a brace, to a cast. Measures to decrease swelling and pain include ice, elevation, and medication.
Fractures that are not in correct position (alignment) will require repositioning (reduction). This may be accomplished by applying gentle pressure on the bones after pain relief has been obtained (closed reduction). If this maneuver is not successful or not desirable, surgery may be indicated to realign the bone fragments (open reduction). Fractures that change position (unstable) will often require metal implants (fixation devices) to be inserted into the bony fragments to allow a stable and correct position. The material used is known as "hardware" and can consist of wires, screws, pins, rods, or plates. If the fracture site is surgically opened for the insertion of metal fixation the procedure is referred to as an open reduction internal fixation (ORIF). If the metal fixation is applied on the outside of the fracture site as well, it is referred to as an external fixation device or external fixator.
Bone fragments that protrude through the skin (compound fracture) need to be treated in the operating room to prevent infection. This is also the case if the fragments slip back into proper position. The wound requires proper cleaning and treatment. Reduction of this type of fracture is a surgical procedure referred to as an open treatment of an open fracture. These individuals may require antibiotic therapy for several weeks to prevent infection.
Joints that have been both dislocated and fractured may require surgical repair of the joint's supporting structures, as well as treatment of the fracture. Injuries that result in the pulling away of tendons (with a small attached bone fragment) from the bone are known as avulsion fractures and are sometimes treated surgically to reattach the bone fragment and, therefore, the tendon. This is common in injuries to the fingers and ankle.
If bone healing is inefficient and/or ineffective, the process of bone healing may be stimulated or accelerated with a bone stimulator consisting of electromagnetic coils applied over the skin or placed over the fracture during surgery. The application of electromagnetic coils could decrease healing time and, therefore, decrease disability time. Coils are not used for acute fractures. Some fractures can also be treated with ultrasound to accelerate healing.
Pain over an area with a high incidence of occult fractures may be treated with a protective splint or cast and re-examined in 2 weeks. This is common in the wrist (scaphoid or navicular bone) and foot. |
Source: Medical Disability Advisor
| Simple, uncomplicated fractures usually heal in 6 to 12 weeks without loss of function. Any increase in severity of the fracture or added complications will delay recovery for weeks to months and may compromise function. While the fracture may heal, damage to the surrounding structures could result in poor function of an extremity and less than optimum outcome. |
Source: Medical Disability Advisor
| Note on research and authorship The duration and type of rehabilitation treatment required following a fracture are related to the associated soft tissue involvement, as well as the location and type of fracture, and the method of stabilization (Chapman).
The goal of rehabilitation of fractures is to restore functional abilities of the individual (Salter). Rehabilitation primarily emphasizes restoring full range of motion, strength, proprioception and endurance while maintaining independence in all activities of daily living (Bucholz). Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).
Modalities, including cold, may be beneficial for controlling pain and edema (Salter). The individual should be encouraged to continue functional activities to prevent complications of inactivity and bed rest. Depending on the stability of the fracture, range of motion exercises of the adjacent joints may be started immediately and progressed to strengthening exercises as indicated (Chapman).
Bone healing may occur within 6 to 20 weeks; however the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical ‡ | |
| Physical or Occupational Therapist | | Up to 18 visits within 8 weeks | | | | | | | | Surgical | |
| Physical or Occupational Therapist | | Inpatient: daily | | | | | | | | Physical or Occupational Therapist | | Outpatient: up to 16 visits within 8 weeks | |
|
| ‡ Note on Nonsurgical Guidelines: Initiation of rehabilitation will vary based on bone stability, treatment chosen, and the location of the fracture (see specific fracture). |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Serious and life-threatening complications can occur to other parts of the body from material released into the bloodstream at the time of fracture. These include injury to the lungs (emboli of fat or blood clot), blood vessels (vein thrombosis, compartment syndrome) and infection. Fat embolism, an occasional complication of long bone fractures, can occur as a result of bone marrow releasing fat into the veins following a fracture. This fat can lodge in the lungs where it obstructs blood flow or pass into the arteries where it can cause central nervous system changes. Fat embolism occurs 12 to 48 hours following fracture and is capable of producing a wide range of symptoms. These include fever, increased heart rate and breathing, blood-tinged sputum, rash, cyanosis, anxiety, restlessness, altered level of consciousness, convulsions, and coma. Fat embolism is rare but may occur with tibial or femoral shaft fractures. Damage to structures near the fracture, such as blood vessels, nerves, or ligaments will complicate treatment and adversely affect the outcome. Complex regional pain syndrome (RSD) is an example of these problems.
Infection in either the bone (osteomyelitis), joint, or in the soft tissues requires treatment, and can delay healing. Fractures that have been successfully reduced may later shift out of position. This is especially true of fractures around the wrist. Stiffening of joints (contracture) or damage resulting in looseness of the joint (laxity) prolongs treatment. Coexisting trauma that would delay treatment of the fracture can complicate healing.
Cigarette smoking delays bone healing, as does any other problem with blood circulation or oxygen delivery. Noncompliance with treatment (such as removing protective devices) results in motion across the fracture, which prevents or delays healing (nonunion or delayed union). Degenerative arthritis often occurs in joints that have been injured.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids may delay fracture healing. A healthy patient can usually compensate for the effects of a single low dose anti-inflammatory. Patients taking multiple simultaneous anti-inflammatories are at increased risk of delayed fracture union. |
Source: Medical Disability Advisor
| Individuals will require some type of immobilizing device, which could potentially present a safety hazard to themselves or their coworkers. Assistive devices for walking, such as crutches and canes, can potentially decrease manual dexterity and need to be used only on dry, hard surfaces. Individuals will need frequent rest periods and an area to elevate the injured extremity, perhaps even a cot or bed, during the early weeks of treatment. Elevation is to permit control of edema, and in the lower limb to help prevent deep venous thrombosis. Access to ice is advisable to control swelling and pain.
There may be extensive physical and/or occupational therapy appointments to facilitate optimum results and strengthen bone weakened from disuse (osteopenia). Work release time is usually needed for these visits. Occupational therapy work site evaluation of safety issues and work feasibility will be beneficial in situations that seem challenging to the individual and/or employer. Medication use for control of pain is probable during the first weeks of treatment. If medication use is allowed during work time, safety issues need to be addressed as well as drug testing policies. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Were symptoms of a fracture (pain, obvious deformity, swelling, loss of strength and motion) noted on the initial exam?
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Was the diagnosis of fracture confirmed with x-ray? If not, was a follow-up x-ray or bone scan done to rule out a subtle fracture?
-
Was the possibility of joint dislocation ruled out?
Regarding treatment:
- Was treatment appropriate to type and location of fracture?
-
Would individual benefit from a consultation with a specialist, such as an orthopedic surgeon, hand surgeon, or foot surgeon?
-
Was open reduction and internal fixation required? What is the expected outcome?
Regarding prognosis:
- Based on the type of treatment required has adequate time elapsed for recovery (6 to 12 weeks)?
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Did the individual experience any complications that may impact recovery (e.g., fat emboli, deep venous thrombosis, compartment syndrome or infection)?
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Has individual followed prescribed rehabilitative therapy?
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If the recovery has been longer than expected, has individual been re-examined to rule out the possibility of a delayed union or nonunion?
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Does individual have an underlying condition (diabetes, vascular disease, inflammatory disease, osteoporosis, or malnutrition) or associated injury (tendon laceration, compartment syndrome) that may affect recovery?
|
Source: Medical Disability Advisor
| Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, 2002.Chapman, Michael W. Chapman's Orthopaedic Surgery. Philadelphia: Lippincott, Williams & Wilkins, 2001. Salter, Robert, ed. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999. |
Source: Medical Disability Advisor
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