The Coding of the Diagnosis

The diagnosis of a fracture is obtained by combining its anatomic location with its morphological characteristic. The answers to the questions: "Where?" ... and "What?" ... are the key to the diagnosis.

An alpha-numeric coding system was chosen to express the diagnosis in order to facilitate computer storage and retrieval. Two numbers are used to express the location of the fracture. These are followed by a letter and two numbers which express the morphological characteristic of the fracture (Fig. 4).

code.jpg

Fig. 4: Alpha-numeric coding of the diagnosis

Example of the coding of a fracture of a diaphyseal segment: 32-82.1

3 Femur - 2 diaphysis - B wedge fracture - 2 bending wedge - 1 subtrochanteric

Example of the coding of a fracture of a distal segment: 33-C3.2

3 Femur - 3 distal - C complete articular - 3 multi-fragmentary - 2 metaphyseal multifragmentary

Through careful classification and accurate documentation of treated fractures one can create a data base which will greatly facilitate research into effectiveness of treatment.

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