Jim Case

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Jim Case

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Analysis of questions from 2020-09-09 call, following model testing:

Questions (and answers):

• Should we consider ALL fractures as traumatic (e.g. pathological fractures are minor trauma to weakened bone)? [NOTE: This has been the historical representation in SNOMED CT]
  • AG recommended on 2020-09-09 that these concepts be remodeled as traumatic.  Further testing of modeling revision is proposed (see below)
  • Testing of remodeling showed that by creating a generic "Fracture of bone" concept that did not specify whether the fracture was traumatic or non-traumatic allowed for the distinction to be made.  This is based on the determination that by "traumatic, we mean a sufficient physical force that would compromise normal, healthy bone. 
  • Impact of newly propose model on searching and CDS is discussed.
• Can we infer that all non-traumatic fractures are pathological fractures (i.e. requires some predisposing bone pathology)?
  • As described by the definitions provided by Dr. Goldberg, pathologic fractures are usually associated with disease pathology such as neoplasia, while fractures occurring due to decreased bone density are called "insufficiency fractures".  
  • ICD-10 considers fractures occurring in the presence of osteoporosis as pathologic fractures (see M80 - Osteoporosis with pathological fracture), while ICD-11 does not have any codes associating fractures with osteoporosis, although they do refer to pathologic fractures in association with neoplastic disease.  Neither ICD-10 nor ICD-11 recognizes "Insufficiency fractures" (Not a subtype of ICD Fracture types)
  • 46675001 |Osteoporotic fracture (morphologic abnormality)| is currently a subtype of 22640007 |Pathologic fracture (morphologic abnormality)|.  This conflicts with current literature that considers osteoporotic fractures as Insufficiency fractures.  It is proposed to move 46675001 |Osteoporotic fracture (morphologic abnormality)|  to be a subtype of a new concept "Insufficiency fracture", which would be a subtype of 23382007 |Stress fracture (morphologic abnormality)|
    • References
      • https://www.uptodate.com/contents/overview-of-stress-fractures?search=insufficiency%20fracture&source=search_result&selectedTitle=1~47&usage_type=default&display_rank=1
      • https://www.clinicalkey.com/#!/content/journal/1-s2.0-S1546144017302181
• If the distinction between traumatic and pathological fractures needs to be made, how do we interpret the meaning of “Fracture of X”? Do we need specific “Traumatic fracture of X” concepts?
  • Proposed naming as additional descriptions listed below:
    • Add "Traumatic fracture of X" to all concepts under the new grouper term: 1003502008 |Traumatic fracture of bone (disorder)| where such a description does not exist
    • Rename concepts with "Pathologic fracture of X due to osteoporosis" to "Osteoporotic fracture of X", to remove the causal DUE TO relations from the FSN.
    • Rename concepts with "Pathologic fracture of X due to neoplasia" to "Neoplastic fracture of X"

Proposed top level hierarchy for Fracture of bone:

Impact on search and CDS:

The creation of the top level grouper 125605004 |Fracture of bone (disorder)| allows for retrieval of all specific types of fractures for through the use of a simple ECL query, such as 

<125605004 |Fracture of bone (disorder)|:363698007 |Finding site (attribute)|=<<71341001 |Bone structure of femur (body structure)| 

Discussion:

Following discussion, a number of options for modeling fractures as a whole were discussed

Update 11/3/2020:  Based on the discussion and a general consensus that fractures should be agnostic as to mechanism unless specifically stated in the FSN. The DUE TO = Traumatic event relationship has been removed from fracture concepts except where need to preserve proper inferences (e.g. open fractures are by definition traumatic and the DUE TO relationship is needed to classify under "Wound").  This results in pathologic and insufficiency fractures classifying as in prior releases under the fracture of the same bone.  This will appear in the Jan 2021 release.

•  Jim Case to write up options  for modeling fractures as a whole (i.e. agnostic to cause or traumatic)
•  Jim Case  to update modeling of fractures as agnostic to mechanism

Bruce Goldberg