“Pathological” fractures in spinal cord injuries and disorders: Insight into International classification of diseases, ninth revision coding

Abstract

Objective:

Analyses of osteoporosis-related fractures in persons with Spinal Cord Injury or Disorder (SCID) using administrative data often exclude pathological fractures (International Classification of Diseases, Ninth Revision (ICD-9) codes 733.1x). We examined how often lower extremity “pathological” fractures were secondary to osteoporosis.

Design:

Retrospective case–control study, fiscal years 2005-2015.

Setting:

Veterans Health Administration.

Participants:

Veterans with SCID and an ICD-9 code for lower extremity fracture.

Outcome Measures:

Clinical and SCID-related characteristics were compared in pathological and non-pathological fractures. A subset of Veterans with lower extremity fracture had data on fracture etiology from prior electronic health record (eHR) review. Of these, all with eHR-confirmed pathological fractures were considered cases. For each case, four unmatched controls with non-pathological fractures from this subset were randomly selected. Fracture etiology was compared between subsample cases and controls. We sought expert opinion from specialists who care for these fractures to understand their perspectives on what constitutes a pathological fracture and narrate our findings.

Results:

6,397 Veterans sustained 16,279 lower extremity fractures, including 314 (1.93%) pathological fractures in 264 Veterans. Ten of 13 (76.9%) cases of pathological fracture (76.9%) and 82.4% of non-pathological fractures were secondary to osteoporosis. Of the 19 experts surveyed, only two coded osteoporotic fractures as pathological.

Conclusion:

Most pathological lower extremity fractures by ICD-9 codes in SCID are secondary to osteoporosis. Pathological fractures can be considered for inclusion in epidemiologic studies of osteoporosis in SCID when the risk-benefit profile for the study favors capturing all osteoporotic fractures at the expense of some misclassification.

Keywords:

• Spinal cord injury
• ICD-9 codes
• Pathological fractures
• Veterans
• Epidemiology

Data availability statement

The data that support the findings of this study are the property of the United States Government’s Department of Veterans Affairs (VA) and are only available as part of VA approved research activities pursuant to VHA Directives 1200.05(2), VHA 1200.01, and/or VHA 1080.01.

Conflict of interest

No potential conflict of interest was reported by the author(s).

Ethics approval

This article does not contain any studies with human participants or animals performed by any of the authors. For this type of study formal consent is not required.

Additional information

Funding

This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development and Health Services Research and Development, VA IIR 15-294: Best Practices for Management of Fractures in Spinal Cord Injuries and Disorders. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.