a specialized course on introducing the abbreviated injury

For individual use only. Duplication or distribution prohibited by law.

Association for the Advancement of Automotive Medicine an international multidisciplinary organization for crash injury control

A Specialized Course on

Introducing

The Abbreviated Injury Scale – 2005 Update 2008

COURSE TRAINING MANUAL

Copyright 2005, 2008, 2010 – Association for the Advancement of Automotive Medicine 35 East Wacker Dr., Suite 850, Chicago, Illinois 60601-2106, USA AAAM.org

Reprint 2016


TABLE OF CONTENTS Chapter 1: Introduction and Overview Instructor and Participant Introductions Purpose of Course Course Objectives Overview of Course Schedule and Materials

Chapter 2: Introduction to Injury Scaling and the Abbreviated Injury Scale (AIS) Genesis and Evolution of the AIS Current AIS Uses AIS Concepts and Purpose AIS Defined AIS Revisions

Chapter 3: The AIS: Structure, Organization and Contents Dimensions of Severity Severity Code Severity Number Dictionary Chapters Chapter Contents 7-Digit Unique Numerical Identifier Coder Instructions Additional AIS 2005 Capabilities

Chapter 4: Multiple Injuries and the Injury Severity Score (ISS) Multiple Injuries Genesis of the Injury Severity Score ISS Definition Rationale for 3 Body Regions ISS Body Regions Sample ISS Calculation Limitations of ISS Under / Overestimation of ISS

Chapter 5: Injuries Defining “Injury” for Coding Purposes Injury v. Diagnosis Injury v. Etiology Injury v. Outcome Examples of AIS-6 Injuries Types of Injury Blunt Injury Penetrating Injury “Not Further Specified” NFS Injuries Code 9 Injuries Common AIS Injury Terminology

Chapter 6: Injury Coding: Rules and Guidelines AIS Coding Rules AIS Coding Guidelines Assignment of AIS Injuries to ISS Body Regions Standardization — The Golden Rule of Severity Coding

Chapter 7: Abstracting Injury Data Sources and Reliability of Injury Information Ranking of Most Reliable Sources of Injury Information Systematic Approach to Coding Injuries Tips for Dealing with Medical Record


Chapter 8: External, Burns and Other Trauma ISS Body Region AIS/ISS Relationship Anatomy Notes Common Terminology Specific Coding Rules and Guidelines Other “Whole Body” Traumatic Events Chapter 9: Face ISS Body Region AIS/ISS Relationship Anatomy Notes Common Terminology Specific Coding Rules and Guidelines Chapter 10: Chest ISS Body Region AIS/ISS Relationship Anatomy Notes Common Terminology Specific Coding Rules and Guidelines Chapter 11: Abdominal and Pelvic Contents ISS Body Region AIS/ISS Relationship Anatomy Notes Common Terminology Specific Coding Rules and Guidelines Chapter 12: Extremities and Pelvic Girdle ISS Body Region AIS/ISS Relationship Anatomy Notes Common Terminology Specific Coding Rules and Guidelines Chapter 13: Coding SPINE Injuries AIS/ISS Relationship Anatomy Notes Common Terminology Specific Coding Rules and Guidelines Chapter 14: Head/Neck ISS Body Region AIS/ISS Relationship Anatomy Notes Common Terminology Specific Coding Rules and Guidelines Coding Closed Head Injuries Chapter 15: Appendices Glossary of Anatomical and Injury Terms Bones of the Human Skeleton Abbreviations Hospital Symbols Weights and Measures Anatomy References AAAM Resources


INTRODUCTION AND OVERVIEW

• Instructor and Participant Introductions

• Purpose of Course

• Course Objectives

• Overview of Course Schedule and Materials


Page 2

CHAPTER OBJECTIVES

In this chapter students will be introduced to the overall purpose of the workshop and the

specific course objectives.

The goal of this chapter is to ensure that students understand the:

• course objectives

• rationale for the organization of the course

On completion of this chapter, students will be able to:

• understand the objectives of the course

• explain how their participation in this course will enhance their coding skills and their

ability to improve the quality of injury data they collect for their research purposes

Chapter Activities: Lecture

Exercises: None


Page 3

PURPOSE

The coding is done manually without the use of any computerized coding programs. This

course is designed for trauma nurses/coordinators, physicians, hospital records personnel,

researchers and others who are involved in any of the various aspects related to injury

data. It is comprised of didactic sessions and work sessions during which actual hospital

charts are used for coding injuries.

Upon completion of the course, the student should have acquired a background in injury

scaling, tools for interpreting injury information and a proficiency in injury coding. This

course does not teach how to use International Classification of Diseases (ICD) coding.

COURSE OBJECTIVES

Upon completion of the course, the participant will:

• Be aware of the history of injury scaling.

• Understand the purpose of injury severity indices.

• Review basic anatomy relative to AIS/ISS body regions and injury descriptions.

• Demonstrate proficiency in extracting injury information from hospital charts.

• Acquire consistency in interpreting injury information.

• Show competence in “matching” injury information in hospital charts with

corresponding AIS injury descriptions.

• Learn AAAM coding rules and guidelines for AIS and ISS.

• Know how to calculate the ISS.

• Master consistency in using the AIS.

Note: Current computer software programs may not reflect the most current AIS dictionary

information. Therefore, even if your data collection system uses a computerized coding program,

the AAAM urges that a periodic comparison between computerized and manual coding be

conducted to assure the most accurate codes guided by current coding rules.


INTRODUCTION TO INJURY SCALING AND

THE ABBREVIATED INJURY SCALE (AIS)

• Genesis and Evolution of the AIS

• Current AIS Uses

• AIS Concepts and Purpose

• AIS Defined

• AIS Revisions


Page 6

CHAPTER OBJECTIVES

In this chapter, the history of injury scaling and the genesis of the AIS will be briefly

reviewed. The students will be introduced to the reasons for injury scaling, and the

purpose and underlying principles of the AIS.

The goals of this chapter are to insure that students understand:

• the conceptual framework of injury scaling

• how the AIS is defined

• how the AIS is used


• gain an historical perspective on the genesis and development of injury scaling

• define the AIS

• discuss the usefulness of the AIS in research and clinical settings

• appreciate the changes that have been made from one revision to the next and the

reasons for them


Exercises: None

References:

Rating the Severity of Tissue Damage I. The Abbreviated Injury Scale, JAMA 215(2):

277-280, 1971.

Petrucelli E, States JD, Hames LN, The Abbreviated Injury Scale: Evolution, Usage and

Future Adaptability, Accid. Anal. & Prev. 13: 29-35, 1982.

Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study:

Establishing National Norms for Trauma Care, J Trauma 30 (11), 1356-1365, 1990.


Page 7

GENESIS AND EVOLUTION OF THE AIS ORIGINS OF THE AIS

• Need for standardized system

• Classify type and severity of injury from vehicular crashes

• Consensus derived

MOTOR VEHICLE CRASH INJURY INVESTIGATION

• Onsite teams in USA, UK, Europe, Australia – in late 1950s, early 1960s.

• Government and industry multidisciplinary teams – late 1960s.

1969 MULTIDISCIPLINARY TASK GROUP

• Sponsored by the American Medical Association (AMA), the Society of Automotive

Engineers (SAE), and the Association for the Advancement of Automotive Medicine

(AAAM).

• Approximately 75 descriptions of most frequent motor vehicle related injuries.

• Provided standard tool for motor vehicle crash investigation.

• Adopted format from early aircraft accident and industry scales.

AIS CONCEPTS AND PURPOSE

• Simple method to rank injury by severity relative to its importance to the whole body

• Standardize terminology

• Usable for multiple causes of injury

• Injury descriptors organized anatomically

• AIS reflects severity of single injury, unaffected by time, sequela or outcome

• AIS should be more than a threat-to-life scale.

CURRENT AIS USES


Page 8

AIS DEFINED The AIS is an anatomically-based, consensus-derived, global severity scoring system

that classifies each injury by body region according to its relative importance on a 6-

point ordinal scale.

ANATOMICALLY-BASED SCALE • Cerebral contusion

• Liver laceration

• Femur fracture

Advantages of an anatomical scale

• Clinical training is not necessary for collecting injury data.

• Anatomic measurements are not variable as are physiological measurements, which

can be affected by:

• time from injury to treatment

• pre-hospital care

• presence of alcohol/other drugs

• patient’s age and ability to compensate for massive volume losses

CONSENSUS-DERIVED SCALE • Developed and monitored by a panel of arbitrators with various viewpoints, different

areas of injury expertise and many years’ experience

• Agreed to agree despite “disagreement”

GLOBAL SEVERITY MEASUREMENT • Severity is determinable once and not contingent on outcome.

• Example: a femur fracture, by consensus, is an AIS-3, no matter the long term outcome. • Severity is invariant with time

• The AIS code does not change with the point in time at which the patient is

assessed. A femur fracture on day 3 of treatment is the same severity as it is on day

1. The patient’s condition or response to the injury may improve or decline, but the

severity of the injury, by consensus, is the same.

ORDINAL SCALE • Ranking of severity in numerical order. • 1 = minor

• 2 = moderate

• 3 = serious

• 4 = severe

• 5 = critical

• 6 = maximum (currently untreatable)

IN SUMMARY, THE AIS IS FUNDAMENTALLY A “SEVERITY OF INJURY” SCALE

which, in addition to threat to life, includes dimensions such as tissue damage, complexity of

treatment and impairment. It performs well as a measure of mortality, although mortality is not

the sole determinant of AIS severity.


Page 9

AIS REVISIONS REVISIONS AND UPDATES SINCE 1971 1976 • eliminated AIS 6-9 “fatal” codes • redefined AIS 6 as “maximum injury currently untreatable” • created AIS 9, “injured but severity unknown” • clarified certain medical terminology 1980 • revised brain injury section to include both anatomic and level-of-consciousness

descriptors • clarified injury v. outcome, including death • added detail to burn injuries • provided size descriptors for soft tissue external injuries 1985 • included more clinical terminology particularly for thoracic, abdominal and vascular

injuries • introduced penetrating injury codes to expand AIS applicability • added a unique numerical identifier to each injury rubric to assist in computerization

of injury data 1990 • expanded penetrating injury codes • introduced age (<15 years old) to some injury descriptors • included coding guidelines to foster injury data collection comparability 1990 UPDATE-98 • expanded coding rules and guidelines • clarified coding External injuries

• included the Organ Injury Scale (OIS) grades* where these could easily be applied to

existing AIS descriptors

AIS 2005 • Refines injury descriptors to reflect contemporary medical terminology

• Improves specificity of orthopedic injury descriptors**

• Introduces injury locators (e.g. aspect, side)

• Expands the coding of bilateral injuries and other trauma

• Introduces impairment scoring

• Facilitates compatibility between more or less detailed injury data

• Continues to foster intercoder reliability

RESEARCHERS, TAKE NOTE: Do NOT assume that all AIS data are compatible – Know what AIS revision was used.

*

**

Developed by the American Association for the Surgery of Trauma

In cooperation with the Orthopaedic Trauma Association


THE AIS: STRUCTURE, ORGANIZATION AND CONTENTS

• Dimensions of Severity

• Severity Code

• Severity Number

• Dictionary Chapters

• Chapter Contents

• 7-Digit Unique Numerical Identifier

• Coder Instructions

• Additional AIS 2005 Capabilities


Page 12

CHAPTER OBJECTIVES

In this chapter the students will be introduced to the purpose and underlying principles of

the AIS.


• basic structure of the AIS and how it works

• format of the AIS Dictionary

• unique numerical identifier

• organization of instructions to coders throughout the dictionary


• understand what the AIS severity number represents

• appreciate the value of the predot codes

• apply basic instructions to ensure consistency in coding

• browse the AIS Dictionary with ease

• understand uses of postdot localizer codes



Page 13

DIMENSIONS OF SEVERITY

The AIS encompasses many dimensions of severity that change over time as medical

diagnosis and treatment become more sophisticated and as the uses of the AIS are

expanded to include many more types of injuries produced by more causes than

ever before. Thus, these current dimensions: • Threat to life

• Tissue damage

• Mortality: theoretical, expected, actual

• Amount of energy dissipated /absorbed

• Hospitalization: need for intensive care, length of stay

• Treatment cost

• Treatment complexity

• Length of overall treatment

• Permanent impairment

• Temporary and permanent disability

• Quality of life

SEVERITY CODE

AIS SEVERITY CODE

1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Maximum (currently untreatable)

Note: “DEATH” is NOT part of the severity scale

• Death is an outcome and outcomes are measured differently than severity.

• Depending on many variables, a patient with an injury that is either minor, moderate

or maximum severity could die. Therefore, a patient who dies is not automatically

assigned an AIS-6. Note: AIS-4 is NOT twice the severity of AIS-2

• AIS-4 is more severe than AIS-2, but a linear relationship does not exist between the

codes. Note: Injuries within the same code may not be strictly compatible

• Example: A closed tibia fracture may be considered more serious than a fracture of

the alveolar ridge, yet both are AIS-2. If AIS were defined on a decimal scale, the

alveolar fracture might be AIS 2.3, whereas the tibia fracture might be AIS 2.8.

However, both injuries, are still considered moderate. Note: 9 = Unknown

• A code of 9 means that inadequate information exists for assigning an AIS. However,

descriptors assigned a 9 allow classification of traumatic events


Page 14

SEVERITY NUMBER

The AIS single digit severity number indicates: the relative severity of injury in an “average patient”

who sustains the coded injury as his only injury.

“Average” patient initially described as:

• Adult 25-40 years of age

• Free of pre-existing conditions

• Free of treatment complications

• Receiving timely, appropriate care for the injury Applicability to Pediatric Population

• Reviewed by Baker and Pediatric Trauma Surgeons in mid-1980s.

• Found to be appropriate for all but a dozen injuries, most of which fell under the

HEAD Chapter, such as cerebral contusions and hematomas

• Based on this work, the 1990 revision of the AIS incorporated changes to some codes

that are specific to the pediatric population.

DICTIONARY CHAPTERS

CHAPTERS IN THE AIS DICTIONARY

HEAD FACE NECK

THORAX ABDOMEN

SPINE UPPER EXTREMITY

LOWER EXTREMITY, PELVIS AND BUTTOCKS

EXTERNAL (SKIN) AND THERMAL INJURIES; OTHER TRAUMA

INDEX • ~ 2000 injury descriptions distributed across nine chapters

• Chapters in the dictionary are not the same as the body regions used by the ISS (see Chapter 4)

CHAPTER CONTENTS

GENERAL STRUCTURE OF CHAPTERS

Whole Area Vessels Nerves

Internal Organs Skeletal


Page 15

EXCEPTIONS: Head chapter includes one additional section

• Concussive injury Abdominal and Pelvic Contents chapter

• Does not list any skeletal injuries Spine Chapter is divided into 3 sections (unique structure)

• Cervical Spine injuries

• Thoracic Spine injuries

• Lumbar Spine injuries Upper Extremity chapter includes 2 additional sections

• Muscles, Tendons, Ligaments

• Joints Lower Extremity, Pelvis and Buttocks chapter includes 2 additional sections

• Muscles, Tendons, Ligaments

• Joints External and Other Trauma chapter (unique structure) • Soft tissue (skin) injury • Burns • Asphyxia/Suffocation • Caustic agents

• Drowning • Electrical injury • Hypothermia • Whole body injury

7-DIGIT UNIQUE NUMERICAL INDENTIFIER Each entry in the Dictionary has the following components:

• PRE-DOT CODE - 6 digits to the left of the decimal point

• AIS SEVERITY NUMBER - a single digit to the right of the decimal point

• INJURY DESCRIPTION - text

• REFERENCES – to AIS 98 and FCI Numerical identifier (pre-dot code):

• Structure follows general pattern

• Each 6-digit identifier unique

• Greater specificity

• More accurate coding

Example: Femur Fracture NFS

• Injury Description: Femur Fracture • Pre-Dot Code: 853000 • 8 = Body Region • 5 = Type of Anatomic Structure → Skeletal • 30 = Specific Anatomic Structure → Femur • 00 = Level of injury within the specific body region and anatomic structure → NFS • AIS Severity Number = 3

Note: It is not important to memorize this structure, except to know that each is unique and this

provides a more specific tool for more accurate coding.


Page 16

CODER INSTRUCTIONS

A set of generic coding rules that apply across all body regions are included in the AIS

dictionary. These can be found at the beginning of the AIS. Some of these are also

highlighted (i.e., contained in parentheses, brackets or boxed in bold type) in individual

chapters as applicable. These coding rules are discussed in detail in Chapter 6, Injury

Coding: Rules and Guidelines.

Additionally, punctuation and formatting convey precise meanings in the AIS dictionary.

Parentheses

• Contain synonyms for a specific type of injury

• Example: base (basilar)

• Example: under Duodenum – D1 (superior or first part)

• Provide a definition for the injury description

• Example: open laceration (bleeding out externally)

Brackets

• Contain inclusionary or exclusionary information

• Example: contusion NFS [include perilesional edema for size]

• Example: laceration [not from penetrating injury]

• Contain Organ Injury Scale Grade

• Example: stomach contusion; hematoma [OIS Grade 1]

Boxed Bold Type

• Contains directives to assist the coder in the appropriate use of specific

description

• Example: Cranial Nerve NFS Use this description if specific nerve is not known

• Example: Gallbladder NFS Read coding rule for “Duct Involvement”.

• Example: Fracture without cord contusion or laceration with or without

dislocation NFS Code each vertebra separately

Semicolons

• Separate injury descriptors that are comparable in severity

• Example: laceration; perforation; puncture NFS

Italics

• Used for proper-named anatomical structures or injuries, and for OIS grades


Page 17

ADDITIONAL AIS 2005 CODING CAPABILITIES

FUNCTIONAL CAPACITY INDEX (FCI)

Probable degree of functional capacity • One year following injury

• Range 1 (most severe impairment) to 5 (no limitations)

• Assumes single injury

• Assesses ten dimensions of physical and cognitive functioning

FCI is described in detail in the AIS Dictionary on page 15.


Page 18

ADDITIONAL AIS 2005 CODING CAPABILITIES

LOCALIZERS

Further degrees of injury specificity.

• Use enables coder to identify the location of certain injuries on the human frame

• Two components: Localizer 1 (L1) and Localizer 2 (L2)

• Each a two-digit number

• Immediately follows the post-dot AIS severity level in the injury descriptor

Localizer 1 notes side and aspect of an injury

location

• L1 codes 01-07 general

• Used if only side, multiplicity and general

area known or desired to code

• 04 denotes bilateral if no dictionary descriptor

for bilateral injury

• 06 and 07 codes for tooth and jaw injuries,

others as appropriate.

• 10-29 define injury locations within right or left

sides

• Aspect localized to anterior, middle,

posterior, inferior, superior or multiple

aspects of injured structure

• Cerebrum, x0 to x3 used to localize an injury

to a specific lobe

• x4 and x5 are used for lower or upper regions

of structure

• 30-37 similar to 10-29 for bilateral injuries

• Two individual injury descriptors may be

used

• 38-99 localizers added by users according to

specific needs of research

Examples:

Abrasion right chest wall 410099.101

Small subdural hematoma left temporal lobe

140652.423

Localizing Descriptors NFS 00 Localizer 1

right left midline bilateral multiple upper lower

01 02 03 04 05 06 07 08 09

right right right right right right right right right right

anterior/frontal middle/parietal posterior/occipital inferior/temporal/lower superior/upper multiple

10 11 12 13 14 15 16 17 18 19

left left left left left left left left left left


20 21 22 23 24 25 26 27 28 29

bilateral bilateral bilateral bilateral bilateral bilateral bilateral bilateral


30 31 32 33 34 35 36 37


Page 19

Localizer 2 used with Localizer 1 for further

specificity

• 01-24 used to denote individual vertebral or

spinal segments

• If single level involved, code with

appropriate L2 code. If no further

specificity known, L1 code that precedes

the L2 code = 00

Example:

Fracture T6 vertebral body

that is not further specified 650430.20013

• If further specified, the appropriate L1

code should precede the L2 code.

Example: Fracture right side

of T6 vertebral body 650430.20113 Fracture left anterior body

of T6 vertebra 650430.22013 • If injury to an intervertebral segment

(e.g., disc injury), higher level used to

describe location.

Example:

C5/6 disc injury 650299.20005

• 25-28 used to identify finger or toe injured

• Thumb and great toe are individual line

items in the AIS dictionary

• 29-30 intentionally blank

• For single rib injuries, L2 localizer used

after appropriate L1 side or aspect code.

Example:

Fractured left 3rd

rib 450201.10233 • For multiple ribs, options to use L2=00

in combination with L1 = multiple OR

L1=right, left or bilateral with further

localization #31-42 OR list each specific

rib with L1 and L2 codes.

• To denote unspecified number of

multiple adjacent ribs, use most superior

injured rib for L2 code preceded by

appropriate L1 code. • 43-50 individual teeth

• Four locations for each of the teeth named.

• L1 localizers 13, 14, 23 or 24 used to

specify which tooth injured

• For multiple tooth injuries, various L1

multiple injuries codes used with L2 = 00.

Example:

Fractured upper central incisor 251404.10643

Localizing Descriptors NFS 00 Localizer 2

Cervical Vertebrae C1 C2 C3 C4 C5 C6 C7

01 02 03 04 05 06 07

Thoracic Vertebrae T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12

08 09 10 11 12 13 14 15 16 17 18 19

Lumbar Vertebrae L1 L2 L3 L4 L5

20 21 22 23 24

Finger/toe 2 3 4 5

25 26 27 28

29 30

Ribs 1 2

3 4 5 6 7 8 9 10 11 12

31 32

33 34 35 36 37 38 39 40 41 42

Teeth central incisor lateral incisor canine first pre molar second premolar first molar second molar third molar

43 44 45 46 47 48 49 50


Page 20

scalp 51

forehead 52

face 53

eye 54

eyelids 55

ear 56

nose 57

lips 58

neck 59

shoulder 60

arm 61

elbow 62

forearm 63

wrist 64

hand 65

finger 66

torso 67

back 68

flank 69

chest 70

abdomen 71

buttocks 72

genitalia 73

perineum 74

hip 75

thigh 76

knee 77

leg 78

ankle 79

foot 80

toe 81

Body Surface • 51-80 locations on body surface

• Useful for external injuries.

• Specific anatomical areas (ear, nose, etc.) or general

areas (flank, torso, etc.)

• Not meant to be precise, may be user defined for specific

purposes.

Example:

Abrasion left ear 220202.10256

INJURY CAUSE DESCRIPTORS Where cause of injury (COI) information required or desirable

• Four-digit code

• First digit specifies nature of the injury

• 0 = non-intentional injury

• 1 = intentional injury

• Second and third digits represent individual cause of injury

• In outline form so more general or more specific injury causes can be noted

• Fourth digit = zero for most cases but can be used for specific situations if desired.

• Examples for the use of infant and child seats below 1

st COI Digit 4

th COI Digit

Non-intentional = 0 Intentional = 1

infant seat = 2 infant seat forward facing = 3 infant seat rear facing = 4 child seat forward facing = 5 child seat rear facing = 6 booster seat = 7


Page 21

NFS 00 COI 2,3 Digits

Blunt Transport

Road Transport

Vehicle Occupant

Motorcycle

Motorized cycle

Pedalcycle

Other human powered

Pedestrian Other

Large Truck

Driver Side Passenger

Other

Small Truck Driver

Side Passenger Other

Van/SUV

Driver Front Side Passenger

Other Front Mid right

Mid center Mid left

Rear right

Rear center Rear left

Passenger Car Driver

Side Passenger

Other Front Rear right

Rear middle Rear left

Other

Driver

Passenger

Driver Passenger

Driver Passenger

Driver

Passenger

01 02

03

04 05

16 07

08

09 10

11 12

13

14 15

16 17

18 19

20

21 22

23 24

25

26 27

28 29

30 31

32

33 34

35 36

37

38 39

40 41

42

43 44


Page 22

NFS 00 COI 2,3 Digits

Non-Road Transport Train/Rail

Aircraft

Watercraft

Animal

Non-Vehicular, non-transport

Assault

Struck by falling object

Fall

Sport

Other Penetrating

GSW Hand gun

Civilian rifle

Military rifle Stab

Bite Human

Animal

Other Piercing/machine Other

Blast Mine

Explosive device Overpressure only

Other

Building collapse Earthquake/landslide

Flood Hurricane/tornado

Occupant

Pedestrian

Commercial Small/private

Military

Occupant

Struck by

Driver

Passenger

Human (by fist, kicking)

Weapon

Body height or less More than body height

Great height (>20m)

Boxing

Diving Individual sports

Motor sport Snow sport

Swimming, scuba Team sports

Other

45 46

47

48 49

50 51

52

53 54

55 56

57

58 59

60 61

62 63

64

65 66

67 68

69

70 71

72 73

74 75

76

77 78

79 80

81

82 83

84 85

86

87 88

89 90

91 92

93

94 95

96 97

98

99


MULTIPLE INJURIES AND THE INJURY SEVERITY SCORE (ISS)

• Multiple Injuries

• Genesis of the Injury Severity Score

• ISS Definition

• Rationale for 3 Body Regions

• ISS Body Regions

• Sample ISS Calculation

• Limitations of ISS

• Under/Overestimation of ISS


Page 24

CHAPTER OBJECTIVES

In this chapter the students will be introduced to the concept of multiple injuries

and the Injury Severity Score (ISS).


• purpose of the ISS

• basic structure of the ISS and how it works

• calculation of the ISS and what it means

• advantages and limitations of the ISS system


• understand the relative value of the ISS

• recognize the differences between ISS body regions and AIS chapters

• calculate the ISS and understand what it represents


References:

Baker SP, O’Neill B, Haddon W. Long WV, The Injury Severity Score: Development and

Potential Usefulness, Proceedings, Association for the Advancement of Automotive Medicine

18: 58-74, 1974.

Baker SP, O’Neill B, The Injury Severity Score: An Update, JTrauma 16: 882-885, 1976.


Page 25

MULTIPLE INJURIES

• AIS assesses the severity of single injuries

• Patients generally sustain more than a single injury in a traumatic event, especially in

motor vehicle crashes.

• Therefore, a system based on the AIS for assessing multiple injury severity is

necessary.

• Initially, the maximum AIS (MAIS), i.e. the most severe AIS code in a multiply

injured patient, was used.

GENESIS OF THE INJURY SEVERITY SCORE

• Developed by Susan Baker et al in 1971 to assess the severity of multiply injured

patients

• Weighted system that uses the highest AIS severity code between AIS 1 and AIS 5 in

three different body regions

• Widely used by hospitals and epidemiological researchers

• Developed because:

• Nonlinear relationship between the MAIS and mortality

• Higher mortality for same patient with MAIS = 4 than if MAIS = 5, depending on

second injury.

• Simple summation of AIS scores inadequate: for example, mortality (%) of AIS 4

+ AIS 3 = 7 (24%) is less than half the mortality of AIS 5 + AIS 2 = 7 (54%) even

though both cases total 7 based on AIS scores.

ISS DEFINITION

The ISS is the sum of the squares of the highest AIS

in each of the three (3) most severely injured ISS body regions.

A2 + B

2 + C

2 = ISS

RATIONALE FOR 3 BODY REGIONS

• Baker’s studies of the relationship between the combined effects of multiple injuries

and death rates led to ISS calculation.

• Comparable totals of ISS scores (derived using many combinations of AIS codes)

proved to be associated with similar mortality rates.

• Best correlation of ISS score with death rates achieved using 3 body regions

• 2 most severely injured body regions did not correlate as well as 3

• 4 most severely injured body regions did not correlate better than 3

Note: If a patient has injuries in only one or two body regions, these are used to calculate

the ISS, but no more than three body regions can be used.


Page 26

ISS BODY REGIONS

The six body regions used in the ISS are:

1. Head and neck 2. Face 3. Chest 4. Abdominal and pelvic contents 5. Extremities and pelvic girdle 6. External

Head and neck injuries include injury to the brain, skull, cervical spine or neck organs. Asphyxia is assigned to the Head. Injuries to the face include those involving mouth, ears, eyes, nose and facial bones. Chest injuries and injuries to abdominal and pelvic contents include all lesions to internal organs in the respective cavities. Chest injuries also include those to the diaphragm, rib cage and thoracic spine. Drowning is assigned to Chest. Lumbar spine lesions are included in the abdominal and pelvic area. Injuries to the extremities or to the pelvic or shoulder girdle include sprains, fractures, dislocations and amputations. External injuries include lacerations, contusions, abrasions and burns, independent of their location on the body surface. Hypothermia, electrical injury, and whole body injury are assigned to External.

Notes: ISS body regions are not necessarily the same as the AIS chapters

ISS ranges from 1 to 75. An ISS of 75 can be derived in one of two ways: one AIS 5

injury in each of three body regions (5² + 5² + 5² = 75) or a single AIS 6 injury (an AIS 6

is not squared).

A patient with any 9 codes may not have an accurate or complete ISS calculated

depending upon other injuries and other body regions involved. Any patient with a

9 code included in the diagnosis should be excluded from research studies.


Page 27

ISS Body Regions vs. AIS Dictionary Chapters

ISS Body Region AIS Dictionary Chapter

Head/Neck

Head, Neck, Spine (Cervical portion),

Other Trauma (Asphyxia)

Face

Face

Chest

Thorax , Spine (Thoracic portion), Other

Trauma (Drowning)

Abdomen and Pelvic Contents

Abdomen, Spine (Lumbar portion)

Extremity

Upper Extremity, Lower Extremity

External

Penetrating Injury section * and Blunt Soft

Tissue Injury section of each chapter, External (Skin) and Thermal Injuries, Other

Trauma (Electrical Injury, Hypothermia, Whole Body Injury)

* note exceptions in Head and Face Chapters

SAMPLE ISS CALCULATION

Case 1. BODY REGION: FACE

LeFort III fracture with blood loss 20% = AIS 3 BODY REGION: EXTREMITIES AND PELVIC GIRDLE

Femur fracture = AIS 3

Knee dislocation, NFS = AIS 2

ISS = 3² + 3² = 18 Note: In this case, only two body regions are injured.

Case 2. BODY REGION: HEAD

Cerebral contusion, large = AIS 4 BODY REGION: CHEST

Bilateral flail chest = AIS 5 BODY REGION: ABDOMEN AND PELVIC CONTENTS

Spleen laceration NFS = AIS 2 BODY REGION: EXTREMITIES AND PELVIC GIRDLE

Bilateral patella fractures = AIS 2 (code each separately)

ISS = 5² + 4² + 2² = 45 Note: In this case, only three of the four regions may

be used to calculate the ISS.


Page 28

LIMITATIONS OF ISS

For Single Injury of AIS 4 (ISS = 16),

the mortality rate is not the same across body regions.

BODY REGION N % DEATHS

Head & Neck

Face

Thorax

Abdomen

Extremities

163

3

33

19

6

17.2

0.0

6.1

10.5

0.0

Note: While this early study had some small samples,

many studies over the years have substantiated this finding.

The mortality rate for ISS = 17 will depend on how 17 is derived.

All ISS = 17 does not have the same mortality rate.

ISS VALUE AIS TRIPLE N % DEATHS

14

16

17

3,2,1

4,0,0

ALL

4,1,0

3,2,2

265

224

325

133

192

1.1

14.3

8.0

18.1

2.6

UNDERESTIMATION OF ISS

It is fundamental to know to what body region an injury should be assigned.

• Assigning injuries to too few ISS Body Regions can result in an underestimation of the ISS

Example: Lung Contusion AIS 3 and Aorta laceration (abdominal) AIS 4 should be coded as:

Chest 32 = 9

Abdomen & Pelvic Contents 42 = 16

ISS = 9 + 16 = 25

• BUT … if the aorta laceration was mistakenly assigned to the Chest ISS body region, then the

ISS would be 16 instead of 25.

OVERESTIMATION OF ISS • Assigning injuries to too many ISS Body Regions can result in an overestimate of the ISS

Example: Lung Contusion AIS 3 and Aorta laceration (chest) AIS 4 should be coded as:

Chest 42 = 16

ISS = 16

• BUT … if the aorta laceration was mistakenly assigned to the Abdomen/Pelvic Contents ISS

body region, then the ISS would be 25 instead of 16.


Page 29

OTHER SEVERITY INDICES

There are many other severity indices. Two of these include:

• NISS – Sum of the squares of the three highest AIS in any ISS body region.

• ICISS – ICD derived ISS which is the product of survival risk ratios (SRR’s) from each injury

sustained.


INJURIES

• Defining “Injury” for Coding Purposes

• Injury v. Diagnosis

• Injury v. Etiology

• Injury v. Outcome

• Examples of AIS-6 Injuries

• Types of Injuries • Blunt Injury • Penetrating injury

• “Not Further Specified” (NFS) Injuries

• Code 9 Injuries

• Common AIS Injury Terminology


Page 32

CHAPTER OBJECTIVES

In this chapter the students will be introduced to the term “injury” as it applies to

injury severity coding. Once this foundation of information is provided, students will

be instructed on how to differentiate “injury” from causes of injury, diagnosis and

outcome. Students will then be introduced to the special issues and coding rules

related to penetrating injuries. How to prevent “overcoding” that can result in artificially

inflated ISS scores will also be reviewed.

The goal of this chapter is to ensure that students understand:

• the definition of an injury for coding purposes.

• the difference between an injury versus an outcome, diagnosis or cause of injury.

• AIS 6 injuries and their implications for severity coding purposes.


• describe what constitutes injury for AIS

• distinguish “injury” from outcome, diagnosis or cause of injury.

• describe types of injuries for which “over or under coding” may occur if proper coding

rules are not followed.



Page 33

DEFINING “INJURY” FOR CODING PURPOSES

Generally, an injury is defined as: The anatomic lesion resulting from a transfer of energy (e.g.,

mechanical, chemical, thermal) rather than a complication

or immediate sequelae from an injury.

• The AIS includes injuries from the following mechanisms:

• Blunt trauma • Burns

• Penetrating trauma • Selected other trauma

• The AIS does permit coding a limited number of immediate sequelae as “injuries” but

within strictly defined rules. Examples of acceptable sequelae that are coded are:

• hemothorax or pneumothorax

• retroperitoneal hemorrhage

• cerebral edema/swelling

• ischemic brain damage directly related to head trauma

INJURY V. DIAGNOSIS

• Preliminary diagnoses are NOT codeable

• No “suspected”, no “possible”, no “rule out” • Clinical diagnoses alone are not codeable for certain injuries

• Example: coding brainstem laceration or lung contusion requires CT, MRI or

autopsy documentation • Exception: AIS allows some flexibility for coding hard to diagnose injuries

• Example: Cranial Nerve Injuries:

• Cranial nerve injuries oftentimes can only be detected by the type of dysfunction

that exists, such as weakness or paralysis.

• AIS allows coding cranial nerve “contusion” if there is documented cranial

nerve weakness/paresis or subtotal loss of function

• AIS allows coding cranial nerve “laceration” if there is documented cranial

nerve paralysis, or total loss of function.

• Example: Basilar Skull Fractures:

• Difficult to detect on routine radiological studies

• Codeable based on physical signs or manifestations such as periorbital

ecchymosis (raccoon’s eyes), mastoid ecchymosis (Battle’s sign), CSF

rhinorrhea, CSF otorrhea, hemotympanum.

• Note: Coding a basilar skull fracture based on physical signs or manifestations is

permitted only if:

• There is evidence of traumatic head injury (mechanism of injury or other

documented head/brain lesion)

• The physical manifestations cannot be related to a peripheral or facial injury (e.g.,

facial fracture).


Page 34

INJURY V. ETIOLOGY

CAUSATIVE FACTOR AIS INJURY

Hit by car

Stabbed by knife

Fell off roof

Burned in fire

Crushed by truck

Dove head first into shallow water

?

?

?

?

?

?

INJURY V. OUTCOME

COMPLICATIONS ARE NOT CODED AS INJURIES

• Examples: Infections

Pneumonia

Epilepsy following head injury

SEQUELAE OR OUTCOMES ARE NOT CODED AS INJURIES

• Examples: Death

Blindness

Obstruction

Miscarriage

Deafness

Swelling (except for brain)

• Exceptions, but only within strict rules:

Asphyxia

Blood loss

Air Embolism

Hemothorax or pneumothorax

Brain swelling/edema

Compartment syndrome

DO NOT ASSUME THAT A SPECIFIC INJURY HAS OCCURRED SIMPLY BECAUSE

A PARTICULAR OUTCOME OCCURRED.

Examples:

• Presence of a hemothorax or pneumothorax does not mean that a lung laceration

exists. Unless a lung laceration has been documented, this diagnosis resulting from an

insult to the chest would be coded as a thoracic injury with hemothorax or

pneumothorax.

• An external (skin) contusion on the scalp does not necessarily mean a concussion or

other brain injury has occurred.


Page 35

EXAMPLES OF SOME AIS 6 INJURIES BY ISS BODY REGION

HEAD or NECK

Brain stem laceration .................................. 140212.6

C3 or higher, complete cord syndrome ...... 640229.6

FACE None

CHEST

Heart-ventricular rupture ............................ 441014.6

ABDOMINAL or PELVIC CONTENTS Hepatic avulsion ......................................... 541830.6

EXTREMITIES OR PELVIC GIRDLE None

EXTERNAL

2 or 3 burn 90% TBS ........................... 912032.6

Any AIS 6 = ISS 75

Note: When an AIS-6 injury is present, DO NOT STOP CODING.

Continue to assign AIS codes to all other injuries even though the ISS will not change.

Note: DEATH IS NOT AUTOMATICALLY AIS-6. THIS IS A COMMON CODING

MISTAKE. Conversely, AIS-1 does not mean that a death did not occur. For example,

an extreme case is where AIS-1 minor laceration in a hemophiliac could result in death.

In this case, the death would be due to a pre-existing condition or complication, and NOT

the severity of the injury.


Page 36

TYPES OF INJURIES

BLUNT INJURY: Coding Tips • Look for injuries related to the blunt trauma

• Vertebral fractures – look for cord contusions

• If a cord lesion is found, there is no need to code the fracture separately • Abdominal or pelvic injuries – look for organ injuries and retroperitoneal

hemorrhage or hematoma • Periorbital ecchymosis (raccoon’s eyes) – look for basilar skull fracture

• Be careful on this one, as periorbital ecchymosis can also be the result of

direct trauma to the face/eye. • “Crush” injuries – look for injuries to underlying systems and organs

• Identify situation when “crush” means a severe injury versus a

contusion/hematoma. • Blunt injuries to the rib cage can result in fractures, lung contusions/lacerations, flail

chest, pneumothorax or hemothorax, pneumomediastinum or hemomediastinum, etc. • Assess rib cage/thoracic injuries carefully and refer to the detailed AIS coding

instructions to properly code them.

PENETRATING INJURY: Coding Tips • Penetrating injuries that do not injure underlying structures should be coded in the

Whole Area section of the dictionary chapter and assigned to the External ISS body

region. (Note exceptions in Head and Face chapters.)

• Look for bullet “track(s)” through body

• entrance and exit wound(s) (Note: exit wound may not be present)

• straight line or ricochet

• systems injured: organs, bones, vessels, nerves • Look for track(s) of whole bullets, fragments or bullets and/or shotgun pellets • Look for “direct” injuries as well as “indirect” injuries

• direct injury = perforated organ

• indirect injury = contused organ near path of bullet (from energy dissipated from

bullet) • Do not code the overlying skin injury separately

• Example: for a patient with a stab wound to the belly, the abdominal puncture

wound where the knife entered is considered part of the same wound that

perforated the colon. • Bullet wounds associated with fractured bones are coded as “open” fractures.

• A bullet can pass through soft tissue/skin only (completely missing other organs and

systems) and cause only an AIS-1 injury.

• Bullet, shotgun and stab wounds present different issues than blunt injuries.


Page 37

• Descriptions are different: segmental loss, complex tissue loss, perforation of

organs.

• Number of injured structures in a single body region may be high.

• Greater chance of major vascular injury than with blunt injuries.

CODING EXAMPLE

INJURY

DESCRIPTION

CODE

RULE

RESULT

Multiple minor stab

wounds

916000.1

Use EXTERNAL section of

AIS if superficial, minor or

NFS, and body region

unknown or uncertain

The injuries are coded

(collectively) under the

laceration or penetrating

injury code in the External

chapter and assigned to the

External ISS body region.

Minor stab wound

to abdomen

516002.1

Use ABDOMEN – Whole

Area, Penetrating Injury, NFS

when no specific organ or

vessel involvement.

The actual location of the

minor stab wound is

known and the AIS code is

located in the Abdomen

chapter but assigned to the

External ISS body region.

Stab wound to

abdomen with liver

puncture and partial

transection of

superior mesenteric

vein

541820.2

(liver)

and

521604.3

(vein)

Specific organ and vessel

injuries are coded in the

ABDOMEN chapter but NOT

the external injury (i.e.,

pierced surface skin of the

abdomen)

The surface injury is

considered to be part of

the underlying wound and

does not require a separate

code.

“NOT FURTHER SPECIFIED” (NFS) INJURIES

NFS: The “not further specified” category allows for coding injuries when detailed

information is lacking. NFS may relate either to the injury type or to its severity, as

follows:

• Injury Unspecified: means that an injury has occurred to a specific organ or body

part, but the precise injury is not known. For example, the description of a “kidney

injury” could be a contusion or a laceration, but no further information is available.

In this case, the kidney injury must be coded as NFS.

• Severity Unspecified: means that a specific injury (e.g., laceration) has occurred, but

the level of severity is not specifically given or is unclear.


Page 38

CODE 9 INJURIES

Trauma has occurred but no information is available regarding the specific organ or

region injured. Example: Injuries to the Head 100099.9 Use of code 9 allows information to be recorded for frequency counts, but may not allow

the calculation of an accurate or complete ISS depending upon the patient’s other

injuries. Therefore, patients with AIS 9 codes should not be included in research studies.

COMMON AIS INJURY TERMINOLOGY (ACROSS CHAPTERS)

Open fracture: skin overlying the fracture is lacerated; the external laceration is implicit

in the code for open fracture and is not coded separately. (Note: a special definition for

open fracture is used for skull fracture.) Closed fracture: the skin overlying the fracture is not lacerated Articular fracture: fracture involving the joint Comminuted fracture: multiple bone fragments. Displaced fracture: fracture in which two ends of bone are not aligned. Complex fracture: fracture with three or more fragments with the proximal and distal

fragments not touching. Sprains and strains*:

Sprains are to joints: knee, ankle, etc.

Strains are to muscles, tendons, etc. (*Clinicians often use these terms interchangeably) Crush: massive destruction of body part with damage to underlying body systems (e.g.,

skeletal, organ and vascular). Amputation: total loss of body part from trauma or burn. Vessel laceration: same as puncture or perforation. Minor vessel laceration: superficial, incomplete circumferential involvement, blood

loss 20% by volume. Major vessel laceration: rupture, transection, segmental loss, complete circumferential

involvement, blood loss 20% by volume. Thrombosis: includes any injury to the vessel resulting in its occlusion. Muscle laceration: same as rupture, tear, avulsion. 20% blood loss in adults: “rule of thumb” is that this translates into 1000 cc’s (also

see table in AIS Dictionary). Nerve paresis (palsy): subtotal loss of function (assumed to be due to contusion). Nerve paralysis: total loss of function (assume to be due to laceration).


Page 39

Types of Arterial Injuries

Transection

Laceration

Contusion & Segmental Spasm

Aneurysm/ Pseudoaneurysm

A-V Fistula

Intimal Flap


INJURY CODING: RULES AND GUIDELINES

• AIS Coding Rules

• AIS Coding Guidelines

• Assignment of AIS Injuries to ISS Body Regions

• Coding External Injuries

• Standardization — The Golden Rule of Severity Coding


Page 42

CHAPTER OBJECTIVES This chapter stresses the importance of standardization of AIS data. General coding

rules will be reviewed and general coding issues will be discussed so that students

have a framework for dealing with common types of coding problems. All coding

rules are presented with emphasis on standardization of injury description. The goal of this chapter is to ensure that students:

• understand the importance of standardization of data

• learn the coding rules and guidelines On completion of this chapter, students will be able to:

• identify situations for which general coding rules or guidelines apply

• deal with coding external injuries with ease

• understand the significance of “standardization” for injury coding



Page 43

AIS CODING RULES The following coding rules should be learned and applied without exception to insure coding uniformity. • Code conservatively. If there is any question about the severity of an injury based

upon all available documented information, assign it the least severe AIS code in that

injury’s category. For example, a documented liver laceration with no details about its

severity should be assigned AIS code 541820.2. • AIS 6 is used only for injuries specifically assigned severity level 6 in the AIS. AIS 6

is not an arbitrary choice simply because a patient died. • Injury diagnoses described as “probable”, “possible”, or “rule out” are not coded. • Unless proper verification (e.g., diagnostic test results) is in the medical record,

many injuries cannot be coded. This mainly affects internal organ injuries such as the

brain and lung, but also includes spinal cord injuries.

Example: “Cord contusion” [includes the diagnosis of compression,

documented by imaging studies or autopsy] • Codes are not assigned to consequences of injury (e.g., blindness) but rather to the

injury per se (e.g., optic nerve avulsion). Brain death is a consequence that cannot be

coded. • “Foreign bodies” are not injuries and therefore not coded. • Procedures and other treatment interventions are not used to determine the severity

of an injury. Do not upgrade injury severity based on level or type of intervention. • Bilateral injuries of kidneys, eyes, ears and extremities are coded as separate injuries.

In some cases, the dictionary will indicate coding bilateral injuries as a single injury

(e.g., lung injuries) and may assign an AIS code one level higher.

Examples: Internal carotid artery occlusion 121004.4

bilateral 121005.5 Eye avulsion; enucleation 240402.2

bilateral 240403.3

• An open fracture by definition means that the skin overlying the fracture is lacerated

and communicates with the fracture. The external laceration is implicit in the code for

open fracture and is not coded separately. • Multiple fractures to the same bone but in different regions of the bone are coded

separately (e.g., femur fractures to head and to shaft, AIS = 853171.3 and AIS

853221.3). If the specific locations are not known, such injuries are coded as a single

fracture (e.g., multiple fractures to right femur = AIS 853000.3). The maxilla,

mandible, and rib cage are regarded as single structures. • “Soft tissue injury NFS” (910000.1) is coded when the specific lesion (abrasion,

contusion, laceration, or avulsion) is unknown or not required. If the body region is

known, the injury should be coded to the appropriate AIS chapter as

Skin/subcutaneous/muscle/NFS and assigned to the External ISS body region.


Page 44

• “Crush” for coding purposes means destruction of skeletal, vascular and soft tissue

systems. The “crush” description is used only when the injury meets the criteria in the

dictionary. If the “crush” code is used, individual injuries are not coded separately. • When a vessel injury is described as a “transection,” it should be coded as a complete

transection. If “incomplete” transection is stated, one AIS code less severe than

“transection” is used. Examples: abdominal aortic transection is 520208.5; abdominal

aortic laceration with incomplete circumferential involvement is 520206.4. • If a vessel injury occurs in combination with an organ injury, the vessel injury is not

coded separately if it is already included in the organ injury descriptor. In the

following example from the AIS Dictionary, therefore, the renal vessel injury is not

coded separately.

Example AIS Code

Kidney laceration extending through renal cortex, 541626.4

medulla and collecting system; main renal vessel

injury with contained hemorrhage • Branches of vessels are not coded unless they are named vessels and/or are listed

within a specific vessel descriptor. • When more than one injury claims the qualifier “blood loss 20%,” the blood loss is

assigned to the most severe associated injury. • A number of injuries to the skin, vessel lacerations, brain lesions and internal organs

are described in terms of blood loss by volume. The following table should help in

assessing blood loss when information in the hospital chart is not specific, and in

coding these injuries in children.

RULE OF THUMB: 1000cc of BLOOD = 20% BLOOD LOSS IN AVG ADULT

WEIGHT POUNDS

WEIGHT KILOGRAMS

20% BLOOD LOSS / cc’s

220 100 1500

165 75 1125

110 50 750

55 25 375

22 10 150

11 5 75

• For AIS coding, Penetrating Injuries are defined as injuries resulting from gunshot or

stab wounds, or from impalement or spearing-type trauma, with or without damage to

underlying organs or structures.

• Penetrating injury that does not involve internal organs or structures is coded under the

Whole Area section of each chapter. These penetrating injury codes are assigned to the

External ISS body region with the following exceptions:

• Penetrating injury to skull (AIS codes 116000.3, 116002.3 and 116004.5) are

assigned to the Head/Neck ISS body region.


Page 45

• Penetrating injury to the face with massive destruction of the whole face (AIS

code 216008.4) is assigned to the Face ISS body region.


Page 46

• When coding Penetrating Injury that involves internal organs and structures, code all

the internal injuries. Do not code the overlying skin injury. The entry/exit wounds to

the skin are reflected in the severity of the internal injuries.

Example AIS Code

GSW to liver, blood loss > 20% 541824.3

Exceptions:

• If only a description of penetrating injury to a body region is given; e.g. GSW to

abdomen, 516000.1 or GSW to abdomen with > 1000 cc blood in belly, 516006.3. • If a penetrating injury to the brain crosses more than one region (e.g., entry into

cerebrum and exit cerebellum). In this case, use 116004.5, “Penetrating injury,

major” under Whole Area section rather than specific site in the brain. Penetrating

injury to the brain stem is an AIS 6 injury and should be coded there even if two

regions of the brain are involved. • If, by using the penetrating injury description, a higher severity score results; e.g.,

GSW to head resulting in subdural hematoma, small (140652.4) and mild diffuse

swelling (140662.3). In this case, use Penetrating Injury > 2 cm deep to cerebrum

(140692.5).

Each section in the dictionary, except spine, has a whole area penetrating injury code

that should be used when information is lacking or to cover the above three exceptions

to the coding rule. • Vague descriptions such as “blunt trauma” or “closed head injury,” are not specific

diagnoses and cannot be assigned an AIS code. If such a description is the only

information available, it can be assigned a 7 digit AIS code ending in .9. Such codes

are included under each section in the dictionary (e.g., Injuries to the Head NFS,

Injuries to the Whole Abdomen NFS). The inclusion of these vague descriptions can

be a useful tool to quantify the frequency of such injuries in trauma databases. It

should be emphasized that injuries which are assigned these NFS codes cannot be used

in calculating an ISS and cases with such codes may have incomplete or inaccurate

ISS scores, depending upon the patient’s other injuries.

• The use of “not further specified” (NFS) allows for coding injuries when detailed

information is lacking

Injury unspecified means that an injury has occurred to a specific organ or body part,

but the precise injury type is not known. For example, the description of a “kidney

injury” could be a contusion or a laceration, but no further information is available. In

this example, the kidney injury is coded as NFS. Severity unspecified means that a specific injury (e.g., laceration) has occurred, but

the level of severity is not specifically given or is unclear. In this example, the injury

should be coded as laceration NFS.


Page 47

AIS CODING GUIDELINES

• If, after carefully reviewing the documentation in the medical record, you do not have

enough detail about an injury to code it, do not guess what it is. Assign a code 9.

Otherwise, your trauma data will not be accurate. • Carefully refer to the AIS dictionary descriptions to assign severity codes. If a

physician describes an injury as severe, do not automatically assign the injury AIS-4.

Physicians are not consistent in the use of terms such as minor, moderate and severe.

Rely on the AIS definitions and match them to the facts in the chart. • The organ injury grading system may be helpful in determining injury severity, but the

grades should not be used as a substitute for clinical descriptions of injuries. Specific

information in the hospital chart about depth of laceration, vessel involvement, or

extent of penetration associated with an organ injury should take precedence over a

surgeon’s designation of a particular OIS grade for that injury. However, if no

relevant detailed descriptive clinical information is available, it is reasonable to rely on

the OIS grade recorded.

• Familiarize yourself with injury terminology in use at your hospital or institution and

how it correctly translates to AIS descriptions.

• It is not correct to assign a higher AIS code when you know there is a hemorrhage but

you do not know the specific source of the bleeding.

Example: Scalp, arm and ulnar nerve lacerations with blood loss > 20% - it is not

correct to code the scalp laceration as AIS-3 because you do not know to what

area of the body the hemorrhage is linked.

• Do not double count injuries. Information on the same injury may appear in different

source documents; do not code the same injury twice.

Example: The ED record refers to R femur fracture while the OR report describes

an open reduction of a L femur fracture. Was there an error in the ED

documentation (“R” written instead of “L”), or are there really two distinct

fractures? Investigate further to code the correct number of injuries. For

example, check x-ray reports. • Look for “coexisting” or associated injuries. For example, if rib fractures have

occurred, a lung contusion is not unlikely. Follow the specific rules for coding

coexisting injuries. • Routinely record the key dimensions of lesions – this may be helpful for determining

severity. The dimensions used by clinicians to describe lesions may vary depending

upon the type of injury and/or part of the body involved.

Example: Skin lacerations are normally described by length in centimeters (cm) or depth

– superficial or deep (into subcutaneous tissue). Avulsions are typically described by

area (cm²). • Routinely record information about volume of blood loss. For an adult, 5000cc is

considered to be 100% of blood volume; therefore, blood loss of > 1000cc (l liter) is

the AIS cutoff for determining a more severe injury.


Page 48

• Routinely record information about immediate sequelae because this may impact the

overall severity of the injury. Although the AIS is a system for assigning severity to

injuries rather than outcomes, it does make some exceptions and information about

sequelae or outcomes is useful in determining their severity.

Examples: • Rib fractures with or without hemothorax

• Head trauma with loss of consciousness

• Nerve laceration with paralysis • Routinely collect the age of the patient. AIS severity is age-adjusted for about a dozen

injuries in the brain and for burns. The ages for which adjustments are necessary vary

according to the injury.

STANDARDIZATION

THE GOLDEN RULE OF SEVERITY CODING

• Like the originators of the AIS, you will encounter codes with which you will not

agree.

• However, it is fundamental that you honor the codes and the coding rules in order to

ensure consistency in the pool of injury severity data.

• If problems exist in the codes, they will eventually surface with enough analysis, but

only if consistency is maintained. Corrections can then be implemented.

• If you identify a code or coding rule that requires review, submit your query to

the AIS Committee ([email protected])

• Inventing your own coding rules defeats the main purpose of injury severity scaling.

You will lose the ability to compare your data to others and even yourself over time.


ABSTRACTING INJURY DATA

• Sources and Reliability of Injury Information

• Ranking of Most Reliable Sources of Injury Information

• Systematic Approach to Coding Injuries

• Tips for Dealing with Medical Records


Page 50

CHAPTER OBJECTIVES

In this chapter students are instructed how to systematically proceed with

abstracting injury information. The quality of different sources of injury information

will be discussed and the medical record will be emphasized.


• strategy for retrieving injury information

• fundamentals of abstracting data from medical records

• hierarchy of injury information sources as it pertains to accuracy and detail


• describe the most reliable sources in a medical record for injury descriptions

• describe a situation when pre-hospital injury information may be useful

• develop a systematic approach to abstracting a medical chart


References:

MacKenzie EJ, Shapire S, Eastham JN, Rating AIS Severity Using Emergency Department Sheets vs.

Inpatient Charts, J Trauma. 25(10), 984-988, 1985.

Streat SJ, Civil ID, Injury Scaling at Autopsy: The Comparison with Premortem Clinical Data,

Proceedings 33, 169-181. Association for the Advancement of Automotive Medicine, 1989.


Page 51

SOURCES AND RELIABILITY OF INJURY INFORMATION • Some sources are better than others

• autopsy or medical examiner reports will be more detailed and complete than ED

records • Rely on the “best” sources of information

• “best” source of information may vary by type of injury; for example:

- fractures may be best described on radiology reports

- organ lacerations may be best described on operative reports • When faced with contradictory information, rely on the source that is most reliable

(use following Ranking Chart as a guide)

• For example: ambulance run sheet states – “fracture to thigh”; but operative report

states – “fracture, distal femur, into articular surface”.

Reminder: Patient-reported brief loss of consciousness (LOC) or reports by bystanders of

LOC without corroboration by EMS or medical personnel cannot be used for coding

purposes.

RANKING OF MOST RELIABLE SOURCES OF INJURY INFORMATION

Medical Examiner/Autopsy Reports

Hospital/Medical Records Autopsy Reports

Operative Reports

Radiology Reports

Nursing or ICU Notes

Physician Progress Notes

ED Record

Discharge Summary

Face Sheet (Discharge Summary Sheet)

“Field” Records Ambulance Run Sheets

Police Reports

Bystander

Patient (esp. LOC) Lowest

Highest Level of General Reliability, Completeness or Detail Lowest


Page 52

SOURCE ADVANTAGES DISADVANTAGE(S)

Medical examiner’s

reports

• very detailed

• complete listing of injuries

• rarely available

• requires extra steps to obtain

Autopsy reports • very detailed if well done • brain exam may be skipped

because time consuming;

therefore some injuries may be

missed

• can be sketchy if not well done

• not available for all deaths

Operative reports • very precise if well done

• external measures usually

described

• frequently typed

• not available for all injuries

Radiology reports/

imaging studies

• usually good source of injury

detail

• complete descriptions

• especially good for fractures

• misdiagnosis possible

or sometimes not conclusive

(e.g., rib fractures)

Nursing or ICU notes • good for description and

location of external injuries

• sometimes contains graphics

of external injuries

• often best source of duration

of LOC

• sometimes illegible

Physician progress notes • precise and useful, but only

within specialty

• detail sometimes lacking

• often illegible

ED record • good descriptions of external

injuries, esp. nurses’ notes

• many non-verified diagnoses

Discharge summary • legible high level “overview”

of case

• variability in completeness of

injury details

• often skips or misdiagnoses

injuries depending on who is

dictating

Face sheet

(discharge summary)

• contains list of diagnoses

• contains ICD codes

• not complete

• insufficient detail

“Field” records

Ambulance run sheets

Police reports

• contains information about

condition at scene, LOC,

blood loss

• may be incomplete

• not always available

Bystander • may have witnessed injury

event

• may be unreliable

Patient (self-reported) • may report useful information

about injury event or

causative factors

• may be unreliable


Page 53

TIPS FOR DEALING WITH MEDICAL RECORDS

Each chart “tells a story” about what happened to the patient • consider everything found in the chart

• information about severity may be scattered throughout the chart

• resist the urge to stop reading parts of the “story” too soon; e.g. a closed head

injury, NFS described early in the chart may be possible to code through

information found later in the chart.

• understand the “big picture” of what happened

• look for the overall logic of what happened

• look for injuries that are consistent with what happened; e.g., a person who was

hit by a car would be expected to have more than one injury

• avoid double counting injuries; look for possible relationships between injuries; e.g., is

the right leg laceration related to the right leg open fracture? (If it is, do not code it

separately.)

• avoid undercounting injuries; look for multiple and bilateral injuries

• when you see two injuries documented as “right femur fracture,” investigate what

you really have: multiple fractures to the right femur or is this a handwriting

mistake and there are bilateral femur fractures?

• look for logical explanations for the injuries described and their outcomes; e.g., a

person with a “crushed” upper arm who is released from hospital the day after

admission does not fit the description of a person with AIS 4 severity; “crush with

massive destruction of skeletal, vascular, nervous, and tissue systems.”

• be aware that clinicians may use terminology that does not match AIS terminology • collect information about all injuries

• even if a patient sustains an AIS 6 injury, code all other injuries as well

• for each injury, record key descriptive information: size of lesion or laceration,

location, multiplicity, amount of bleeding, neurological deficits, etc. • do not use treatment as a substitute for the injury descriptor

• just because a laceration was sutured does not mean that it fits the AIS definition

of a major laceration

Be complete and consistent in your approach to each injury case.


Page 54

SYSTEMATIC APPROACH TO CODING INJURIES

• Read medical record carefully. If you are not sure what the injury terminology is

describing, look it up in the AIS Dictionary index or in a medical dictionary. • List injuries and note their source (e.g., operative report). • List details

• size, depth, etc.

• multiple, bilateral, coexisting injuries

• pertinent immediate sequelae. • Note if patient’s age is < 10 (for appropriate age adjustments) • Locate injuries in the AIS Dictionary. Descriptions in the medical record and those in

the AIS Dictionary will not always match precisely. It can be helpful to read the AIS

synonyms or use medical resources. • Record 7-digit AIS code. • Assign each injury description to the proper ISS Body Region • Calculate the ISS • Note any problems (e.g., a code 9 may mean an incomplete or inaccurate ISS

depending upon the other injuries and/or body regions).


EXTERNAL ISS BODY REGION

• AIS/ISS Relationship

• Anatomy Notes

• Common Terminology

• Specific Coding Rules and Guidelines

• Other “Whole Body” Traumatic Events


Page 56

CHAPTER OBJECTIVES

In this chapter the students will review coding rules and guidelines specific to the

External body region. Students will work in groups and independently in abstracting

injury information from actual medical charts, in assigning accurate AIS codes and in

calculating the ISS for each case.

The goal of this chapter is to ensure that students:

• understand the unique coding rules and guidelines relevant to this body region

• gain practice in abstracting injuries and coding the accurately through a succession of

cases at different levels of difficulty


• abstract appropriate injury information from medical charts.

• choose appropriate AIS codes for documented injuries.

• apply appropriate rules or guidelines for AIS codes when injury information is lacking.


Exercises

Discussion


Page 57

AIS/ISS RELATIONSHIP The AIS External (Skin) and Thermal Injuries, and Other Trauma chapter includes External

(soft tissue) injuries, burns and other traumatic events.

The External ISS Body Region includes lacerations, contusions, abrasions and burns,

independent of their location on the body surface (except) amputation burns that are assigned to

the appropriate body region). Other traumatic events assigned to this ISS body region are:

electrical injury, frostbite, hypothermia and whole body injury.

ANATOMY NOTES

What AIS defines as part of External

• Skin, subcutaneous tissue, muscle (unspecified or multiple body regions)

• Burns, except burn amputations

• Other “whole body” traumatic events

COMMON TERMINOLOGY

• Following are the injury descriptions used in the AIS External chapter:

• abrasion

• contusion

• laceration

• avulsion

• degloving injury

• penetrating injury

• burn • External injury descriptions may vary internationally. Following is a compilation of

descriptions from international faculty:

• Abrasion - A rubbed or scraped area on skin or mucous membrane caused by contact with

a rough surface or object with sufficient force to remove surface layer(s). Friction

removes the epithelial layer and can also remove part of the epidermis so deeper layers are

exposed.

Other terms: scratch; scrape; graze; road rash; friction burn • Contusion - A black and blue mark resulting from a blunt force which causes tiny

underlying blood vessels to burst and leak blood into the skin without causing a break in

the skin.

Other terms: bruise; contused wound; ecchymosis; subcutaneous hematoma; bump;

subgaleal hematoma • Laceration - Tear or ripping apart of tissues resulting from a blunt or penetrating force.

Superficial lacerations involve the epidermis and dermis, whereas more severe lacerations

involve deeper layers including subcutaneous tissue and muscle.

Other terms: open flesh wound; scrub wound (Aust); cut; chop wound (Hong Kong); gash

• Avulsion - Ripping or tearing away of all the layers of skin in which a portion is separated

from underlying tissues often creating a flap; may be thought of as equivalent to a full

thickness skin graft excision • Degloving - Traumatic removal of skin and subcutaneous tissue separating tissue planes

from their blood supply, especially from a limb (oftentimes described as like removing a

glove). An example is a hand being caught by and then dragged into a vise with the skin

and subcutaneous tissue being pulled away from the underlying tissues.


Page 58

Deglovings may be open (as described in the example above) or closed (Morel-Lavallee

lesion), as may occur as result of shearing effect when a limb is run over by a vehicle tire,

separating the subcutaneous tissue from the underlying fascia and muscle, often creating a

cavity filled with hematoma and liquefied fat. Deglovings are usually more extensive than

an avulsion injury.

Other terms: decollement (Japan) Decollement injury is equivalent to the closed degloving

injury. • Penetrating Injury - For AIS coding, penetrating injuries are defined as injuries resulting

from gunshot, stab wounds, impalement, or spearing type trauma, with or without damage

to underlying organs or structures.

Other terms: Gunshot wound; shotgun wound; stab wound; cut; traumatic incision; incised

wound; slash; gash; puncture wound.

SPECIFIC CODING RULES and GUIDELINES • External injuries (i.e., those to skin, muscle or subcutaneous tissue) are also called soft tissue

injuries and are dispersed across body regions so that they can be easily located. • “Soft tissue injury NFS” (910000.1) is coded when the specific lesion (abrasion, contusion,

laceration, or avulsion) is unknown or not required. If the body region is known, the injury

should be coded to the appropriate AIS chapter as Skin/subcutaneous/muscle/NFS and

assigned to the External ISS body region. • If a skin injury, including penetrating injury, occurs in isolation (i.e., no underlying injury), it

is coded under the appropriate AIS section BUT assigned to the External body region when

calculating ISS.

Example: Chin laceration

AIS Code: Face (210600.1)

ISS Body Region: External • The AIS External (Skin) and Thermal Injuries chapter should only be used if no

information is available locating the injury on a specific body part or area. Multiple minor

external injuries to one or more ISS body regions may be coded as one injury (AIS 1) using

this section, e.g., “overall abrasions” = 910200.1; “multiple lacerations” = 910600.1. • When a skin injury occurs in combination with an underlying injury, both are coded under the

specific body region

Example: Chest wall bruising (410402.1); lung contusion (441402.3)

The skin injury is assigned to ISS External body region

The internal thoracic injury is assigned to the ISS Chest body region

Exceptions:

Open fractures: Soft tissue injury is included in “open fracture” definition and

therefore it is not coded separately Penetrating injuries: The underlying structure(s) is/are coded and the overlying

skin injury is not coded separately.

• Penetrating injuries that do not involve underlying structures are coded in the Whole Area

section of each chapter and assigned to the External ISS body region.

Exceptions:

Head: All penetrating injuries coded in the Whole Area section are assigned to

the Head ISS body region Face: Massive destruction of the face (216008.4) found in the Whole Area

section is assigned to the Face ISS body region.


Page 59

Burn Injuries

[Note: The AIS is not intended to be a comprehensive burn scale]

• The Diagram of Nines is used to assign percentage of total body surface area (TBSA) burned;

e.g., “second degree burn of arm” = maximum of 9% TBSA. • Depth of burn

• 1st degree = superficial

• 2nd

degree = partial thickness

• 3rd

degree = full thickness • Age adjustment is required for burns (<1 year old for 1

st degree, <5 years old for 2

nd and 3

rd degree).

• If burns are only described as combined degrees, code to the most severe.

Example: 18% first and second degree burns is assigned 912012.2

• When burns occur in varying degrees assign an AIS code to the first degree burns separately

from second and third degree burns. If second degree burns are less than 10% TBSA and/or

third degree burns are < 100 cm2 or > 100 cm2 but < 10%, then both the second and the third

degree burns should be coded separately. If the combined second and third degree burns cover

> 10% TBSA, assign the AIS code based on their combined TBSA.

Example 1: Adult sustains 40% first degree burns, 5% second degree burns and 2% third

degree burns.

Code: 912002.1 for the 1st degree burns

912006.1 for the 2nd

degree burns

912008.2 for the 3rd

degree burns

Example 2: Adult sustains 40% first degree burns, 15% second degree burns and 5%

third degree burns.

Code: 912002.1 for the 1st degree burns

912018.3 for the combined 2nd

degree burns and 3rd

degree burns

• If a burn amputation is the direct result of the event, code as an amputation using the specific

body region. Do not code the burn separately. If an amputation is made sometime after the

event, code the burn only. In the latter case, the amputation is considered treatment.

• If an electrical injury includes “flash” burns, code only the electrical injury.

OTHER “WHOLE BODY” TRAUMATIC EVENTS

• Several new injury descriptors have been added in AIS 2005.

• Frostbite is assigned to the External ISS body region.

• Asphyxia/suffocation is assigned to the Head ISS body region.

• Caustic agent ingestion injuries are assigned to the region of the specific organ that is injured.

• Caustic agent inhalation injuries are assigned to the Chest ISS body region.

• Drowning is assigned to the Chest ISS body region.

• Hypothermia – code the whole number of the temperature. Do not round up or down.

Hypothermia is assigned to the External ISS body region.

• Whole body injury with massive chest and abdominal injuries including the loss of one or

more limbs or decapitation is an AIS 6 injury. These codes refer most typically to blast-type

injuries and are assigned to the External ISS body region.


FACE ISS BODY REGION


• Anatomy Notes




Page 62

CHAPTER OBJECTIVES

In this chapter the students will review basic anatomy of the Face, including its skeletal

structures and organs. Coding rules and guidelines specific to the Face body region will

be discussed. Students will work in groups and independently in abstracting injury

information from actual medical charts, in assigning accurate AIS codes and in

calculating the ISS for each case.


• understand the unique coding rules and guidelines relevant to the Face ISS body

region

• gain practice in abstracting injuries and coding them accurately through a succession

of cases at different levels of difficulty


• abstract appropriate injury information from medical charts

• choose appropriate AIS codes for documented injuries

• apply appropriate rules or guidelines for AIS codes when injury information is lacking


Exercises

Discussion


Page 63

AIS/ISS RELATIONSHIP The AIS Face chapter includes injuries to eyes, ears, nose, mouth and facial bones. The

ISS Face Body Region includes the same injuries.

ANATOMY NOTES What AIS defines as part of face

• Skin (external soft tissue) on front and sides of head, including forehead

• Facial bones include hyoid, palatine, zygoma, mandible, maxilla, nasal

• Orbits of eyes

• Vessels: only vessel included is external carotid and its branches (facial and internal

maxillary)

• Nerves: only nerve included is optic (intraorbital portion)

COMMON TERMINOLOGY Type of facial bone fracture

• Closed (simple)

• Open (compound)

• Comminuted

• Non-displaced

• Displaced

Location of fracture (for AIS coding)

• Upper third of face

• Supraorbital ridge and above

• Middle third of face

• Nasal bones and septum

• Maxillary sinuses (antrum)

• Orbital bones (i.e., eye socket)

• Zygoma

• Zygomatic arch

• Maxilla

Transverse (LeFort I)

Pyramidal (LeFort II)

Craniofacial disjunction (LeFort III)

• Alveolar process

• Maxillary dentition (teeth)

• Lower third of face

• Mandibular dentition (teeth)

• Alveolar process

• Symphysis/parasymphysis

• Corpus or body

• Angle

• Ramus

• Condyle

• Coronoid process


Page 64

The following descriptions of LeFort fractures supplement those in the AIS dictionary. LeFort I (transverse horizontal maxillary alveolar fractures, Palate-facial disjunction,

[Guerin fracture]): occurs through the lower maxilla into the nasal cavity including the

maxillary alveolar process, portion of the maxillary sinus, the hard palate and the lower

aspect of the pterygoid plates. Fracture detaches the tooth-bearing portion from the rest

of the maxilla with one fracture line. There are usually no airway complications with this

fracture.

Clinically – slight swelling; maxilla will move independently of the

remainder of the face; possible malocclusion. LeFort II (pyramidal disjunction): Fracture line passes through the nasal bone, lacrimal

bone, floor of the orbit, infraorbital margin, across the upper portion of the zygomatic-

maxillary suture line and maxillary sinus and pterygoid plate along the lateral wall of the

maxilla into the pterygopalatine fossa. Two fracture lines result in a floating maxilla and

nose with a possible cribriform plate fracture.

Clinically – massive edema; nose is obviously fractured; possibility of

CSF (cerebrospinal fluid) leak. LeFort III (craniofacial disjunction): Complete separation of the facial bones from their

cranial attachments creating the most complex of all facial fractures. Fracture passes

through the nasofrontal suture, the junction of the ethmoid and frontal bone, the superior

orbital fissure, lateral wall of the orbit, zygomaticofrontal and temporal suture, with a

high fracture of the pterygoid plate producing a dish face deformity that is difficult to

correct secondarily. Three fracture lines.

Clinically – massive edema; zygoma is mobile; orbital rim is mobile;

diplopia if involving blowout fracture of orbit; depression of cheekbone;

open bite; possibility of CSF leak.

SPECIFIC CODING RULES AND GUIDELINES

• Under Whole Area, some smaller sized soft tissue injuries are equivalent in severity to

larger sized (whole area) injuries elsewhere on the body; e.g., a major laceration is

defined as >10cm long and into subcutaneous tissue versus >20 cm long for most other

body regions. • Bilateral injuries to eyes or ears are usually coded as separate injuries except where

specifically noted in the dictionary. • Traumatic enucleation of the eye is coded as eye avulsion. • Alveolar ridge fracture, including injury to teeth, is coded as a single injury. • Injuries to teeth (any number) without involving the alveolar ridge are AIS 1 injuries. • Bilateral fractures to maxilla or mandible are coded as single injuries with location

assigned to the fracture located in the largest mass area of the bone. • Nose fractures that accompany a LeFort I fracture should be coded as a separate

injury. Nose fractures that accompany LeFort II and III fractures are, by definition,

included in the LeFort fracture and therefore are not coded separately.


Page 65

• Facial fractures must be significantly displaced to be coded as “displaced”. Minimal

displacement should not be coded as a displaced fracture.

• Panfacial fractures (a new descriptor in AIS 2005) are defined as multiple and

complex fractures that may involve the middle and lower face, upper and middle face,

or all three locations, but are not LeFort fractures. A panfacial fracture is usually

secondary to a high-velocity injury and results in multiple fracture fragments

resembling a jigsaw puzzle.

Facial Trauma: LeFort Types

The transfacial fractures can be divided into LeFort type 1, type 2, and type 3. When you find

components, these can be mixed and matched depending upon the additional components you

may see. As was previously stated, you must have a fracture line extending through the pterygoid

plates to have a LeFort type of injury. If it is just extending through the maxilla, not involving

the nasal arch itself, or the orbital rims, then you have a LeFort type 1. If it extends up to involve

the inferior aspect of the orbital rim, but does not extend up through the lateral wall, then you

have a LeFort type 2. All of these again are extending back to involve the pterygoid plate. The

type 2’s can extend through the nasal bone as well, and the type 3’s can tend to extend across the

region of the glabella and the zygomatic process.


Page 66

Facial Trauma: LeFort Type 1

Diagrammatic representation of the LeFort type with a bony fragment. Important to identify is

the facial instability that will be associated with these and it needs to be brought to the attention

of the surgeons so that they can go in with microplates and resecure these bony fragments.


Page 67


LeFort type 2 in another diagrammatic representation shows how you would expect to see that

fracture line extending through.


Page 68


LeFort type 3 with transorbital sort of involvement. It may only involve ½ of the face. You may

have a LeFort type 2 on the left and a LeFort type 3 on the right, or you could even have a LeFort

type 1 just involving part of the maxilla on one side of the face and LeFort type 3 on the other

side.


Page 69

Fractures of the Midface*

Le Forte Fractures

LeForte studied fracture patterns of the midface at the turn of the century and determined that

there were great lines of weakness in the face (Figure 6). He characterized the most common

transverse fractures of the mid-face and proposed a classification that still bares his name.

Figure 6. The transverse fracture lines associated with a LeForte I, II, and III fracture pattern.

A LeForte I fracture is a split of the maxilla along a horizontal line below the nose and extending

through the naso-maxillary, zygomatico-maxillary, and pterygo-maxillary buttresses. This

fracture pattern results in a “floating palate” separated from the rest of the facial bones. The

fracture disrupts the normal alignment of the teeth (malocclusion).

A LeForte II fracture is a pyramidal split of the maxilla above the nasal bridge, extending

diagonally through the infra-orbital rim coursing along the zygomatico-maxillary, and pterygo-

maxillary buttresses. This fracture pattern results in the displacement of the nasal pyramid, as well

as malocclusion.

Finally, a LeForte III fracture is also known as craniofacial disjunction. The face is fractured

through the lateral orbital wall, coursing along the orbital floor, to include the nasal bridge, and

extending through the septum and the pterygomaxillary buttress. This fracture essentially

separates the face from the cranium. Aside from malocclusion and facial asymmetry, this type of

fracture can effect the position and function of the ocular globes.

_____________________

* Reprinted with permission from SAE P-276 “Head and Neck Injury” © 1994 Society of Automotive Engineers, Inc.


Page 70

Malar Complex Fractures The malar complex is also known as the cheek bone. The anatomic bone associated with this area

of the face is the zygoma. Since the cheek bone is also a projected highlight region of the face, it

is also subject to a high frequency of fracture. Other names for fractures of the zygoma include “tripod fracture” (Figure 7) because the bone

usually fractures at three points and separates from the side of the face. The fracture pattern

involves the lateral orbital rim along the greater wing of the sphenoid bone coursing through the

infra-orbital rim and the zygomatico-maxillary buttress, and involves a separate fracture through

the zygomatic arch.

Figure 7. A zygomatic fracture.

The zygoma is often broken at three points and the resultant injury is then termed a tripod fracture.

Concerns of zygoma fractures include those described previously about the orbital floor, since a

portion of the floor is made up of the zygomatic bone. In addition, the contour of the face can be

affected leaving a “flat cheek bone,” and the displaced zygomatic arch can lead to difficulty

opening the mouth (trismus) because of interference with the coronoid process of the mandible.

Naso-Orbito-Ethmoid Fractures NOE Fractures

A NOE fracture is a characteristic fracture pattern involving many bones but centrally located in

the mid-face (Figure 8). As the label implies the nose, orbit, and ethmoid are involved. This

fracture results from a central impact to the face.

Figure 8. A naso-orbito-ethmoid fracture (NOE) includes these named bones

and can be quite devastating to the structure of the mid-face.


Page 71

Concerns regarding an NOE fracture pattern are loss of nasal height and increase in nasal width

since the impact on the midface drives the nose back into the skull. The medial orbital walls are

separated as the nasal and ethmoid bones are driven between them, resulting in wide-set eyes. If

the force of the fracture is severe, the base of the cranial vault can also be fractured opening up a

fault line communicating with the brain.

Pan Facial Fractures A pan-facial fracture is a devastating injury involving the entire face (Figure 9). It is usually

secondary to a high-velocity injury and results in multiple fracture fragments resembling a jigsaw

puzzle. In the past, such injuries had an extremely high mortality rate; however, with the onset of

rapid response rescue teams and sophisticated trauma centers, the survival rate is increasing.

Such advances in life saving ability have left plastic surgeons with very challenging

reconstructive problems.

Figure 9. When a high-velocity injury results in multiple fractures of the face

in several different regions, it is termed a pan-facial fracture.


CHEST ISS BODY REGION


• Anatomy Notes




Page 74

CHAPTER OBJECTIVES

In this chapter the students will review basic anatomy of the Chest, including its

skeletal structures, organs, vessels and thoracic spine. Coding rules and guidelines

specific to the Chest body region will be discussed. Students will work in groups and

independently in abstracting injury information from actual medical charts, in assigning

accurate AIS codes and in calculating the ISS for each case.



• gain practice in abstracting injuries and coding them accurately through a

succession of cases at different levels of difficulty





Exercises

Discussion


Page 75

AIS/ISS RELATIONSHIP

The AIS Thorax chapter includes all injuries to internal organs and vessels in the chest

cavity, including the diaphragm and rib cage.

The ISS Chest Body Region consists of all the injuries in the AIS Thorax chapter, the

thoracic spine (AIS Spine chapter), and drowning from Other Trauma (AIS External

and Other Trauma chapter).

ANATOMY NOTES

What AIS defines as part of the chest

• Skin (external soft tissue) of entire upper region of torso (excluding shoulder girdle

and sternoclavicular regions)

• Trachea and esophagus below the sternal notch, bronchus, diaphragm, heart, lungs

• Rib cage and sternum

• Thoracic vessels including thoracic portion of the aorta and vena cava

• Thoracic spine, both vertebrae and cord

What is not part of the Chest ISS Body Region

• Larynx and vocal cord (Head/Neck ISS Body Region)

• Shoulder (Extremities and Pelvic Girdle ISS Body Region)

COMMON TERMINOLOGY

• “Crush” is defined as massive bilateral destruction of skeletal, vascular, organ and

tissue systems.

• Open chest wound is defined as “sucking” chest wound.

• Organ injury scale (OIS) grades are included for some thoracic injuries.

• The parietal pleura is a slick membrane that lines the chest cavity; the portion

enveloping the viscera within the cavity is the visceral pleura. The space between the

two pleurae is the intrapleural space.

• When the intrapleural space fills partly or completely with air, blood or a mixture of

both, the descriptive terms are pneumothorax, hemothorax, or hemopneumothorax

respectively. The presence of air is related to tears in the airway or chest wall; the

presence of blood signifies torn blood vessels.


Page 76

SPECIFIC CODING RULES AND GUIDELINES • Esophagus and trachea are included in both Neck and Thorax chapters of the dictionary. See

the dictionary for specific instructions regarding assignment of injuries to the correct region.

• The rib cage is treated as a single anatomic structure for coding fractures without flail and for

bilateral flail. Unilateral flail chest and rib fractures without flail are coded only as flail. If a

flail chest is documented on one side (unilateral) and fractured ribs without flail are

documented on the other side, code as two separate injuries.

• Flail chest is defined as three or more adjacent ribs each fractured in two or more places.

• “Multiple” rib fractures, if documented but not further specified (NFS), have a specific code.

• Costal cartilage fracture or tear should be coded as a rib fracture. “Clinical rib fractures” are

not coded. Radiologic, operative, or autopsy substantiation is required.

• Lung contusions must be consistent with history of chest trauma and must be verified by

radiograph, autopsy, or collaboration of the physician. Clinical pulmonary dysfunction is

insufficient evidence for coding.

• Coexisting injuries such as rib fractures and lung contusions or lung lacerations are coded as

separate injuries.

• When chest trauma is only described by its sequela and no specific injury information is

available, the section “Thoracic injury” should be used.

• Hemo/pneumothorax and hemo/pneumomediastinum are consequences of chest trauma.

However, they are coded separately because oftentimes these conditions are the only

documented evidence of chest trauma or, if they occur with chest injury, the combination can

be more serious than only the anatomic injury.

• Other codable immediate sequelae are air embolus, or tamponade.

• Blast and inhalation injuries to the chest are coded in the “Lung” section.

• Ingestion injuries in the chest are coded under “Esophagus”.

• Lung lacerations must be substantiated by CT, operative report or autopsy.

• Vessel injuries are coded separately from other injuries in the chest, except for crush-type or

massive penetrating injuries which are inclusive of all injuries to the chest.

• The AIS does not list every artery and vein in the chest. When a specifically identified

(named) vessel has a documented injury but that vessel is not specifically listed in the AIS,

use the categories called “other named arteries” or “other named veins”.

• Branches of vessels are not coded unless they are named vessels or are listed within a specific

vessel descriptor.

• Aorta and vena cava injuries can occur in either the chest or abdomen. The specific location

of these injuries is important information for coding. While the severity of the AIS code will

be the same for either region, the ISS may vary depending on what other injuries are present

in the chest or abdomen.

If a vessel injury is described as “incomplete transection”, it is coded as incomplete

circumferential involvement.


Page 77


Page 78


ABDOMINAL AND PELVIC CONTENTS ISS BODY REGION


• Anatomy Notes




Page 80

CHAPTER OBJECTIVES

In this chapter the students will review basic anatomy of the Abdomen and Pelvic

Contents, including organs, vessels and lumbar spine. Coding rules and guidelines

specific to the Abdomen and Pelvic Contents body region will be discussed. Students

will work in groups and independently in abstracting injury information from actual

medical charts, in assigning accurate AIS codes and in calculating the ISS for each case.










Exercises

Discussion


Page 81


The AIS Abdomen chapter consists of all injuries to the internal organs of the abdominal

and pelvic cavities, and all injuries to the retroperitoneal region.

The Abdominal and Pelvic Contents ISS Body Region is comprised of injuries from

the AIS Abdomen chapter and the Lumbar Spine section of the AIS Spine chapter.

ANATOMY NOTES

What AIS defines as part of the abdominal and pelvic contents

• Skin (external soft tissue) of entire lower region of torso (excluding hip and buttocks

areas)

• Digestive (except esophagus), intestinal, genitourinary and biliary system organs,

adrenal gland and spleen

• Abdominal and pelvic vessels, including abdominal portion of aorta and vena cava

• Lumbar spine, both vertebrae and cord

What is not part of the Abdominal and Pelvic Contents ISS Body Region

• Torso organs above diaphragm (Chest ISS Body Region)

• Hip and pelvic girdle (bony structure) (Extremities and Pelvic Girdle ISS Body Region)

COMMON TERMINOLOGY

• Synonyms for massive organ laceration are: avulsion, complex, rupture, tissue loss,

deep.

• “Avulsion” of an organ involves ripping away the organ from its vascular

attachment.

• “No perforation” is defined as partial thickness laceration, such as a serosal tear.

• “Perforation” is defined as full thickness laceration, but not complete transection.

• “Transection” is defined as complete separation of two parts of a structure.

• Organ injury scale (OIS) grades are included for many abdominal organ and vessel

injuries, but grades should not be used as a substitute for clinical descriptions of

injuries.


Page 82


• If retroperitoneal hemorrhage or hematoma occurs in combination with other thoracic

or abdominal injury, code it separately only if it can be determined that it is unrelated

to the other injury. The following organs or structures, when injured, may cause

retroperitoneal hemorrhage: pancreas, duodenum, kidney, aorta, vena cava,

mesenteric vessel; also pelvic or vertebral fractures.

• The AIS does not list every artery or vein in the abdomen. When a specifically named

vessel has a documented injury but that vessel is not specifically listed in the AIS, use

the categories called “other named arteries” or “other named veins.”

• Branches or vessels are not coded unless they are named vessels and/or are listed

within a specific vessel descriptor. • Vessel injuries are coded as separate injuries if: (1) they are isolated injuries or (2) if

they are not included in an organ injury description.

• If an injury occurs at the junction of the duodenum and jejunum, code to the jejunum. • Bilateral organ (e.g., kidney) injuries are coded separately.

• The term “rupture” is used for kidney, liver or spleen injury only when more detailed

information is not available.

• The terms “minor,” “major” or “massive” are accepted as severity descriptions only

when they are the only terms available in the medical record to describe the injury.

• Positive peritoneal lavage is not codeable information; the bleeding must be linked to a

specific injury

• If an organ sustains both a contusion and laceration, assign each injury the appropriate

AIS code if they are unrelated. If the organ laceration has an accompanying contusion

or hematoma, code only the laceration.

• Fetal demise as a result of abdominal injury to a pregnant female is a consequence and

therefore not coded.

• Abdominal compartment syndrome is a consequence of trauma and therefore is not

coded.

• Duct involvement applies to gallbladder, liver and pancreas. Injuries to these organs,

which share the same duct system, often involve injuries to the duct system of each

organ. When only one ductal injury occurs, it should be assigned to either (not both)

of the two involved organs. When separate ductal injuries occur, each should be

assigned to the appropriate organ.


Page 83


Page 84


Page 85

Digestive System of Man (Diagrammatic)


Page 86

MAN – Liver and Kidney Systems


EXTREMITIES AND PELVIC GIRDLE ISS BODY REGION


• Anatomy Notes




Page 88

CHAPTER OBJECTIVES

In this chapter the students will review basic anatomy of the upper and lower extremities

and the bony pelvis. Coding rules and guidelines specific to the Extremities and Bony

Pelvis body region will be discussed. Students will work in groups and independently in

abstracting injury information from actual medical charts, in assigning accurate AIS

codes and in calculating the ISS for each case.










Exercises

Discussion


Page 89


The AIS Upper Extremity and Lower Extremity, Pelvis and Buttocks chapters

include sprains, fractures, dislocations and amputations.

The Extremities and Pelvic Girdle ISS Body Region consists of injuries from the AIS

Upper Extremity and Lower Extremity, Pelvis and Buttocks chapter.

ANATOMY NOTES

What AIS defines as part of Extremities and Pelvic Girdle

• Skin (external soft tissue) of entire upper and lower extremities, including shoulder,

hip and buttocks. Assign skin injuries to External ISS body region.

• Muscles, tendons, ligaments.

• Extremity vessels.

• Acromioclavicular, sternoclavicular, elbow, wrist, hand, hip, knee, ankle and foot

joints.

• All long bones of upper and lower extremities.

• Pelvis including: acetabulum, ilium, ischium, coccyx, sacrum and pubic ramus.

COMMON TERMINOLOGY • Joint capsule laceration includes rupture, tear, avulsion.

• Nerve contusion code should be used for diagnosis of “palsy”.

• “Crush” implies massive destruction of bone, muscles, nerves, vessels, cartilage and

vascular system.

• Bones are fractured; joints are dislocated or sprained.

• Tears of a ligament are termed sprains; tears of muscles or tendon fibers are termed

strains.

• A degloving injury is tearing away and detachment of skin and neurovascular

structures from bone.

• No distinction is made between “closed” fractures and those “not further specified”.

They are assigned the same 7-digit numerical identifier.

• “Articular,” “extra-articular” and “partial articular” refer to involvement of a joint surface.

• Dislocation is complete separation of a joint.

• Subluxation is a partial dislocation.

• Overall severity of pelvic fractures is related to “stability” or “instability”. (See

definitions of stability in AIS dictionary in chapter on Lower Extremity, Pelvis and

Buttocks.)


Page 90


• Penetrating injury to bone and tissue is coded as an open fracture to the specific bone.

• Thumb and non-thumb fingers are separate injury categories.

• Degloving injuries are assigned to the External ISS body region.

• Fracture descriptors such as open or stable may affect the severity of certain bones.

“Closed” and “displaced” have been deleted in the Extremity chapters since they are

not considered to significantly affect injury severity. Closed fracture, when given as

the only descriptor, is coded as fracture NFS.

• Long bone fractures are classified as to their location on the bone (i.e. proximal, shaft

[diaphyseal] or distal. Proximal and distal long bone fractures are further classified by

their degree of complexity and the extent of articular (joint) involvement (see

illustrations in AIS dictionary).

• “Complex fracture” is defined as three or more fragments with proximal and distal

fragments not touching.

• The pelvis is divided into two anatomic structures for AIS coding: the pelvic ring and

the acetabulum. The pelvic ring is assigned only one fracture code no matter the

number of fractures to its specific aspects. The acetabulum may be assigned two

fracture codes depending on whether the injury is unilateral or bilateral.

• The pelvic ring consists of two arches: anterior and posterior. The severity of the

pelvic ring fracture is related to the extent of damage to the posterior arch and any

resulting instability.

• The acetabulum is classified by anterior or posterior column. The anterior column

extends form the anterior half of the iliac crest to the pubis. The posterior column

extends from the greater sciatic notch to the ischium.

• A partial articular fracture of the acetabulum may be one of two types: a fracture

involving only one column, or a fracture with a transverse component but with a part

of the articular surface remaining attached to the ilium.

• A complete articular fracture of the acetabulum is one in which both columns are

disrupted from each other and the attachment between the articular surface and the

posterior ilium no longer exists.

• Eponyms are provided in italics, where appropriate, to describe certain lower

extremity joint and bone injuries.

• AIS 2005 provides significantly increased specificity for both amputation and

penetrating injuries.

• Bilateral proximal amputations are assigned only one code.

REFER FREQUENTLY TO ILLUSTRATIONS IN THE AIS DICTIONARY FOR ACCURATE CODING


Page 91

EXAMPLES OF PELVIC FRACTURES

Stable Partially Unstable Totally Unstable

Isolated simple

fracture of:

Sacroiliac joint with anterior

disruption

Sacroiliac joint with posterior

disruption

Pubic ramus

Ilium

Ischium

Lateral compression fracture

“Open book” fracture < 2.5 cm

Vertical shear fracture

Public ramus fracture with

sacroiliac fracture/dislocation

Transverse fracture of

sacrum and coccyx With or without

sacrococcygeal dislocation

Wide symphysis pubis separation

(>2.5 cm)

Anterior compression fracture of

sacrum

Fracture involving posterior

arch with complete loss of

posterior osteoligamentous

integrity

Minor symphysis pubis

separation (< 2.5 cm)

Fracture involving posterior arch

with posterior ligamentous

integrity partially maintained

Fracture involving posterior arch,

but pelvic floor intact

Bilateral fractures with posterior

ligamentous integrity partially

maintained

Fracture involving posterior

arch with pelvic floor

disruption

The crucial factor to determine the level of pelvic instability (partial or total) will depend

entirely on the extent of damage to the posterior ligaments and/or pelvic floor.


CODING SPINE INJURIES


• Anatomy Notes




Page 94

CHAPTER OBJECTIVES

In this chapter the students will review basic anatomy of the Spinal Cord and Vertebral

Column. Coding rules and guidelines specific to the Spine will be discussed. Students

will work in groups and independently in abstracting injury information from actual

medical charts, in assigning accurate AIS codes and in calculating the ISS for each case.










Exercises

Discussion


Page 95


The AIS Spine chapter is comprised of injuries from the Cervical, Thoracic and Lumbar

Spine and is unique in its format. No Whole Area, Vessel, Nerve or Skeletal sections are

included in this chapter.

The ISS does not have a separate Spine body region

• Cervical injuries are included in the Head/Neck ISS Body Region

• Thoracic injuries are included in the Chest ISS Body Region

• Lumbar injuries are included in the Abdominal and Pelvic Contents ISS Body Region

SPINAL CHAPTER HIGHLIGHTS • Formatting

• Structure

ANATOMY NOTES

What AIS defines as part of the Spine

• Spinal cord

• Vertebrae

• Disc

• Brachial plexus

• Nerve root

• Ligaments and tendons

COMMON TERMINOLOGY

• Spinal cord injury is defined as damage to neural elements in the spinal canal (spinal

cord and cauda equina).

• Level of injury refers to the most caudal segment of the cord with normal motor and

sensory function.

• Incomplete cord syndrome is defined as preservation of some sensation or motor

function; includes anterior cord, central cord, lateral cord (Brown-Sequard)

syndromes. “Incomplete quadriplegia” or “incomplete paraplegia” should be coded as

an incomplete cord injury.

• Complete cord syndrome is defined as quadriplegia/tetraplegia or paraplegia with no

sensation or motor function.

• Cord laceration, transection and crush are included in the same injury description.

• Plexus contusion is synonymous with stretch injury.

• Dislocation is synonymous with subluxation.

• “Whiplash” is synonymous with cervical strain.


Page 96


• The Spine chapter requires coding coexisting injuries to the cord and to the vertebral column

as a single injury; for example, cord contusion with paraplegia and associated

fracture/dislocation is a single injury and is assigned only one AIS code. In such cases, the

fracture/dislocation is not coded separately.

• If the cord and/or spinal column is injured in more than one location each injury is coded

separately.

• Cord contusions/lacerations must be verified by x-ray, CT scan, MRI, myelogram or autopsy.

• If it is not clear whether the cord was contused or lacerated, code as contusion.

• For cervical spine injuries, the level of cord injury (i.e., superior or inferior to C4) will affect

AIS severity in complete injuries.

• Codable immediate sequelae associated with spine injuries include: transient neurological

signs (paresthesia), incomplete cord/cauda equina syndrome (hemiplegia), complete cord/

cauda equina syndrome (paraplegia, quadriplegia/tetraplegia), and radiculopathy.

• The neurological status of a patient with paralysis directly related to spinal cord injuries

should be coded according to its status at 24 hours post injury. If fatal within the first 24

hours, code the neurological status at time of death.

• “Spinal Cord Injury Without Radiological Abnormality” (SCIWORA) describes a syndrome

of post-traumatic neurologic injury without evidence of fracture or ligamentous injury on

plain radiographs or CT. With the advent of MRI, most patients who would previously have

been diagnosed with SCIWORA have demonstrable radiographic findings. However, if

SCIWORA is still used, it should be coded as spinal cord contusion NFS. This diagnosis is

most commonly attributed to the cervical region unless symptoms clearly describe thoracic or

lumbar injury.

• Vertebral dislocation (e.g., C5-6 subluxation) is coded as one injury and assigned to the

superior vertebra.

• An AIS code for vertebral dislocation is only assigned when there is no fracture or cord

involvement.

• Each vertebral fracture should be coded as a separate injury if there is no associated spinal

cord injury.

• Vertebral fractures are coded as body, laminae, spinous and transverse processes, facets,

pedicles, and odontoid of C2 depending on the specific location of the fracture.

• If a vertebra sustains more than one fracture (e.g., transverse process and facet), code as

multiple fractures of same vertebra, except for odontoid or major compression fractures which

are coded additionally.

• A fracture described as to the “lateral mass” is coded to the pedicle.

• A “burst” fracture is coded as a vertebral body compression fracture.

• The amount of compression in vertebral body fractures will affect the AIS code.

• Spinal coding algorithm

• Is the cord involved?

• Is it a contusion or laceration?

• Are neurologic symptoms transient, incomplete or complete?

• Is there a fracture, dislocation or both?


HEAD/NECK ISS BODY REGION


• Anatomy Notes



• Coding Closed Head Injuries


Page 98

CHAPTER OBJECTIVES

In this chapter the students will review basic anatomy of the Head and Neck including its

skeletal structures and organs. Coding rules and guidelines specific to the Head and

Neck body region will be discussed. Students will work in groups and independently in

abstracting injury information from actual medical charts, in assigning accurate AIS

codes and in calculating the ISS for each case.


• understand the unique coding rules and guidelines relevant to the Head/Neck ISS body

region

• gain practice in abstracting injuries to the anatomic structures in this body region and

coding them accurately through a succession of cases at different levels of difficulty


• abstract appropriate injury information from medical records

• choose appropriate AIS codes for documented injuries

• apply appropriate rules or guidelines for AIS codes when injury information is lacking


Exercises

Discussion


Page 99

AIS/ISS RELATIONSHIP The AIS Head chapter includes skull fractures, injuries to the brain, cranial nerves and vessels

and concussive type injuries. The AIS Neck chapter includes injuries to the organs, nerves and

vessels within the neck. The Cervical Spine section of the AIS Spine chapter includes injuries

to both the cord and vertebrae within the cervical region. The ISS Head/Neck Body Region includes injuries to the skull and brain (AIS Head chapter),

neck (AIS Neck chapter) and cervical spine (AIS Spine chapter) and asphyxia.

What is not part of the Head/Neck ISS Body Region

• Forehead (Face ISS Body Region)

• Trachea below sternal notch (Chest ISS Body Region)

• Esophagus below sternal notch (Chest ISS Body Region)

ANATOMY NOTES – HEAD What AIS defines as part of the Head

• scalp

• skull

• brain

• intracranial vessels (carotid artery must be intracranial portion)

• cranial nerves

Anatomical Structures

• scalp – very vascular structure

• galea – covering over skull (subgaleal hematoma)

• skull – outer and inner tables with cancellous bone in between

• meninges – dura mater, arachnoid, pia mater

• brain regions – brain stem, cerebellum, cerebrum

Skull Fractures – base or vault

• base – with or without cerebral spinal fluid (CSF) leak

• vault – depressed, linear, compound, open

• clinical signs of base fracture – periorbital ecchymoses, Battle’s sign, CSF

rhinorrhea or otorrhea

Focal and Diffuse Brain Injuries

• focal – space occupying lesion in brain which creates shift or herniation

• contusions

• hematomas – epidural (extradural), subdural, intracerebral (intraparenchymal)

• intraventricular hemorrhage

• subarachnoid hemorrhage

• diffuse – widespread, global damage affecting consciousness

• concussion – mild to severe

• diffuse axonal injury (DAI) is sometimes referred to as white matter shearing. DAI is a

clinicopathological complex defined as immediate and prolonged coma due to widespread

damage to axons and other neuronal processes in the brain. The AIS dictionary includes a

detailed discussion and definition that coders should become totally familiar with before

coding DAI.


Page 100

COMMON TERMINOLOGY – HEAD

• “Crush” is massive destruction of cranium (skull), brain and neurovascular system.

• Vessel thrombosis is a vessel injury that results in occlusion (e.g. intimal tear, dissection).

• “Compound” is a term uniquely used in the skull to mean open fracture.

• Open skull fracture means compound fracture plus torn dura.

• The terms brain swelling and brain edema are often confused because in many regions of the

world, they are intentionally used interchangeably. In other regions, however, they are

considered to be separate entities. The subtle differences between these two conditions are

described in the Head chapter of the AIS dictionary.

SPECIFIC CODING RULES AND GUIDELINES – HEAD

• Coding of brain injuries should be done at 24 hours or at initial confirmed diagnosis if later

than 24 hours.

• Loss of consciousness (LOC) is coded only when there is convincing evidence of head trauma

and the diagnosis is made by a physician. The Glasgow Coma Score (GCS) is only one

indicator of brain injury and should never be used as the sole indicator. BEWARE of

inappropriate use of “loss of consciousness”. No one with a GCS=9 or higher is

unconsciousness; most, but not all, with a GCS=8 are unconscious; all with a GCS8 are

unconscious.

• “Closed head injury” (CHI) and “traumatic brain injury” (TBI) are non specific diagnoses.

The AIS assigns a code of 100099.9 which indicates that trauma has occurred, but it cannot be

used to calculate an ISS.

• When vessel and head injuries occur simultaneously, both should be coded. If a specific

vessel is injured but not named, code the injury as vascular injury in the head, NFS.

• Note new “bilateral” codes introduced in AIS 2005.

• With cranial nerve injuries, unless contusion or laceration is specified, code the injury as a

laceration if there is total loss of nerve function (paralysis). Code the cranial nerve injury as a

contusion if subtotal loss of function (paresis/palsy) is documented.

• Brain injuries are coded only when verified by CT scan, MRI, surgery, x-ray, angiography or

autopsy. Clinical diagnosis alone is not sufficient. [This rule applies to all internal organ

injuries.]

• Size, location, and multiplicity of brain lesions may affect injury severity.


Page 101

• Edema accompanying a contusion or hematoma (perilesional edema) is considered part of the

lesion when assessing its size.

• A description of “closed cisterns” implies brain swelling.

• The severity of injuries to children 10 years and younger has been adjusted in the AIS.

• Code all skull fractures under vault unless specified as base. If skull fractures to both vault

and base are documented, code both fractures. If a single skull fracture involves both base

and vault, code the more severe. If both are of equal severity, code the fracture to point of

origin.

• Fracture of the base of the skull (basilar) may involve any of the following bones: ethmoid,

sphenoid, orbital roof, and portions of the occipital and temporal bones (petrous and mastoid

portions of the temporal bone).

• Given evidence of head injury, any of the following clinical signs can be used to corroborate a

diagnosis of basilar skull fracture: hemotympanum, perforated tympanic membrane with

blood in canal, mastoid hematoma (“Battle’s sign”), CSF otorrhea, CSF rhinorrhea, periorbital

ecchymosis (“raccoon eyes”). Caution: do not automatically assume that all cases of

periorbital ecchymosis are basilar skull fractures – could also indicate orbit fractures or

simply soft tissue contusions.

• Code as diffuse axonal injury if the injury is diagnosed on imaging and described using terms

such as white matter shearing, shear injury, or DAI, is associated with immediate prolonged

coma (a clinical sign), and meets the definition of DAI given in the AIS dictionary. Be

sure to read the specific coding rules for DAI when choosing a DAI code.

• DAI may be coded in the Cerebrum or Concussive Injury section of the Head chapter. DAI

that lasts more than 24 hours is always coded in the Concussive Injury section. Review the

DAI coding rules in those sections of the AIS dictionary carefully before assigning a DAI

code.

• Certain findings including intraventricular hemorrhage, ischemic brain damage, subarachnoid

hemorrhage, and subpial hemorrhage are not coded when a DAI diagnosis is confirmed.

• Under Cerebrum, several descriptors of imaging findings include coma as a modifier (i.e.,

intraventricular hemorrhage, ischemic brain damage directly related to head trauma,

subarachnoid hemorrhage and subpial hemorrhage). If a patient sustains more than one of

these documented findings involving coma, assign the coma only once to the finding that will

result in the highest AIS code. If there is no difference in AIS code, add the coma to only one

of the findings and code the other finding(s) as not further specified (NFS).

• “Brain death” is an outcome or sequela and is not codeable.


Page 102

• Code a penetrating injury to a specific anatomical structure (e.g., cerebrum, cerebellum, brain

stem) if this information is known. If the specific site is not known or if more than one

structure is injured, then code to Penetrating Injury under Whole Area.

Exception: Penetrating injury to the brain stem is an AIS 6 injury and should be coded

under brain stem even if two regions of the brain are involved.

• If an injury is described as penetrating but there is no skull penetration, the injury is coded as

a scalp laceration.

• A gunshot wound to the head with entry and exit wounds is coded as a single injury.

CODING CLOSED HEAD INJURIES Search for information in chart so you rarely end up using code 9. It may not be possible

to assign an accurate or complete ISS to cases with any AIS 9 codes, depending upon

injuries in other body regions. EXAMPLE

INITIAL INJURY DESCRIPTION

ADDITIONAL INFORMATION FOUND

AIS CODE

Closed head injury, NFS none 100099.9

Closed head injury Mild concussion, no LOC 161001.1

What AIS defines as part of Neck

• skin (external soft tissue) of neck region, vessels, nerves, esophagus (at junction of

neck/thorax and above), larynx, pharynx (at junction of neck/thorax and above), thyroid

gland, vocal cord and salivary gland

• cervical spine, both vertebrae and cord

COMMON TERMINOLOGY – NECK

• A neurological deficit associated with a vessel injury in the neck is synonymous with stroke.

• “Whiplash” should be coded as cervical spine strain.

SPECIFIC RULES and GUIDELINES – NECK • Recognize that injuries to the trachea and the esophagus may be coded in either the Neck or

Thorax sections of the dictionary. If injury occurs at or above the junction of the neck and

thorax (i.e. the sternal notch), assign to Neck.


Page 103

SKULL OF MAN


Page 104

SKULL OF MAN


Page 105

THE BRAIN OF MAN


Page 106

THE BRAIN OF MAN


APPENDICES

• Glossary of Anatomical and Injury Terms

• Bones of the Human Skeleton

• Abbreviations

• Hospital Symbols

• Weights and Measures

• Anatomy and Terminology – Selected References


Page 108

GLOSSARY OF ANATOMICAL AND INJURY TERMS

A

Abdomen: that portion of the body which lies between the thorax and the pelvis; called also belly and

venter. It contains a cavity (abdominal cavity) separated by the diaphragm from the thoracic cavity above,

and by the plane of the pelvic inlet from the pelvic cavity below, and lined with a serous membrane, the

peritoneum. This cavity contains the abdominal viscera and is enclosed by a wall (abdominal wall or

parietes) formed by the abdominal muscles, vertebral column and the ilia. It is divided into nine regions:

three upper--right hypochondriac, epigastric, left hypochondriac; three middle--right lateral, umbilical, left

lateral; and three lower--right inguinal, pubic, left inguinal.

Abrasion: an area of body surface denuded of skin or mucous membrane by some unusual or abnormal

mechanical process.

Acetabulum: the large cup-shaped cavity on the lateral surface of the os coxae in which the head of the

femur rests.

Acromium: the lateral extension of the spine of the scapula, projecting over the shoulder joint and

forming the highest point of the shoulder; also called acromial process and acromium scapulae

Alveolar ridge: the bony ridge of the maxilla or mandible which contains the alveoli.

Aneurysm: a sac formed by the dilation of the wall of the vessel or the heart.

Angiography, cerebral: radiographic visualization of the blood vessels supplying the brain, including

the extracranial portions, after the introduction of contrast material.

Anterior spinal artery ischemia: bilateral pain and temperature loss below the level of the lesion, but no

vibratory or proprioception loss; a sensory combination called “dissociated sensory loss”.

Anterior spinal artery syndrome (anterior cord syndrome): injury to the ventral spinal cord caused

by blockage of the anterior spinal artery and infarction of the areas it supplies. Below the level of the

lesion complete paralysis, hypalgesia, and hypesthesia occur, but there is relative preservation of the

posterior sensations of touch, position and vibration.

Aorta: the main trunk from which the systemic arterial system proceeds. It arises from the left ventricle

of the heart, passes upward (ascending aorta), bends over (aortic arch), passes down through the thorax

(thoracic aorta) and through the abdomen to about the level of the fourth lumbar vertebra (abdominal

aorta), where it divides into the two common iliac arteries.

Aphasia: loss of impairment of speech (due to trauma).

Artery: a vessel through which the blood passes away from the heart to the various parts of the body. The

wall of an artery consists typically of an outer coat (adventitia), a middle coat (media) and an inner coat

(intima).

Articular: of or pertaining to a joint

Articular capsule: the sac-like envelope which encloses the cavity of a synovial joint; called also joint

capsule and synovial capsule.

Astragalus: talus

Atelectasis: collapse of alveoli

Atrium: one of the chambers of the heart.

Avulsion: the ripping or tearing away of a part in which a portion is separated from underlying tissues

and adjacent parts and left hanging as a flap

Avulsion, major: tearing away of > 25 cm 2 of skin on the face or hand, or >100 cm

2 on the body

but blood loss of 20% or less by volume

Avulsion, superficial: tearing away of < 25 or less cm 2 of skin on the face or hand, or < 100 cm

2

on the body.

Axilla, axillary: refers to the armpit.

B

Babinski’s syndrome: condition in which when the sole of the foot is stroked, the great toe turns upward

instead of downward, indicating an organic lesion in the brain or spinal cord.


Page 109

Battle's sign: discoloration over the skin of the mastoid region of the skull, in the line of the posterior

auricular artery, the ecchymosis first appearing near the tip of the mastoid process; seen in fracture of the

base of the skull.

Biliary duct, common bile duct (choledochus duct): the duct formed by union of the common hepatic

and the cystic ducts which empties into the duodenum at the major duodenal papilla, along with the

pancreatic duct.

Brachial: refers to the arm, or any arm-like process.

Brain stem: the stalk-like portion of the brain connecting the cerebral hemispheres with the spinal cord

and comprising the midbrain, pons and medulla; the diencephalon (hypothalamus) is sometimes

considered part of the brain.

Bronchial tear: Inhaled air leaks into the mediastinum instead of coursing through the bronchial tubes to

the alveoli.

Bronchus: a division of the trachea.

Brown-Séquard's syndrome: (lateral cord) a syndrome due to damage of one half of the spinal cord,

resulting in ipsilateral paralysis and loss of discriminatory and joint sensation, and contralateral loss of

pain and temperature sensation; also called Brown-Séquard's paralysis.

C

Calvarium: bony encasement for the brain; the skull

Canaliculus: an extremely narrow tubular passage or channel; a general term for various small channels.

Cardiac tamponade: acute compression of the heart caused by increased intra-pericardial pressure due to

the collection of blood or fluid in the pericardium from rupture of the heart, penetrating trauma or

progressive effusion.

Carotid cavernous fistula: communication between an injured internal carotid artery and the cavernous

sinus or the orbital veins; the veins may swell and press against various ocular nerves, causing visual

symptoms.

Carpal: refers to the wrist, as the carpal bones.

Cavernous sinus: either of two sinuses of the dura mater, located at either side of the body of the

sphenoid bone, extending from the medial end of the superior orbital fissure in front to the apex of the

petrous temporal bone behind. Each cavernous sinus commonly comprises one or more main venous

channels and contains the internal carotid artery and abducens nerve.

Cauda equina: collection of spinal nerve roots descending from the lower part of the spinal cord; their

appearance resembles a horse’s tail

Cauda equina syndrome: dull aching pain of the perineum, bladder and sacrum, generally radiating in a

sciatic fashion, with associated paresthesias and areflexic paralysis, due to compression of the spinal

nerve roots.

Central cord syndrome: see syringomyelia.

Cerebellum: the part of the brain that occupies the posterior cranial fossa behind the brain stem and is

concerned in the coordination of movements. It is a fissured mass consisting of a body, comprising a

narrow middle strip (the vermis) and two lateral lobes (the hemispheres) connected with the brain stem by

three pairs of peduncles. Functionally, the cerebellum is subdivided into a cranial (anterior) lobe, which is

separated from the caudal (posterior or median) lobe by the primary fissure, which is in turn separated

from the flocculonodular lobe by the dorsolateral (posterolateral) fissure.

Cerebral infarction: an ischemic condition of the brain, producing a persistent focal neurological deficit

in the area of distribution of one of the cerebral arteries.

Cerebrum: the main portion of the brain, occupying the upper part of the cranial cavity; its two

hemispheres, united by the corpus callosum, form the largest part of the central nervous system in man.

Chordae tendineae: the tendinous cords that connect each cusp of the two atrioventricular valves to

appropriate papillary muscles in the heart ventricles.

Clavicle: the key-like bone of the shoulder girdle.

Clivus: a bony surface in the posterior skull formed by a portion of the basilar part of the occipital bone

and the upper part by a part of the sphenoid bone.


Page 110

Coccyx: the small bone caudal to the sacrum, formed by union of four (sometimes five or three)

rudimentary vertebrae, and forming the caudal extremity of the vertebral column.

Colon: the portion of the large intestine between the caecum and the rectum.

Coma: term used for prolonged state of unconsciousness. A person with a Glasgow Coma Scale (GCS)

score of 8 or less is considered to be in coma.

Comminuted: broken, fragmented or crushed into small pieces, as a comminuted fracture.

Compartment syndrome: a condition in which increased tissue pressure in a confined anatomical space

causes decreased blood flow leading to ischemia and dysfunction of contained myoneural elements,

marked by pain, muscle weakness, sensory loss and palpable tenseness in the involved compartment.

Concussion, cerebral: a form of diffuse brain injury resulting in an immediate, but transient alteration in

consciousness. Concussion may be mild or classical. Mild concussion is often characterized by a

“dazed, stunned, stars” phenomena. Retrograde and/or posttraumatic amnesia may or may not be present.

In classical concussion, there is a positive brief loss of consciousness and in most cases, there is some

degree of retrograde and/or posttraumatic amnesia.

Condyle: a rounded projection on a bone

Contrecoup: injury resulting from a blow at another site remote from the direct impact.

Contusion: a black and blue mark caused by a direct blow - meaning the blow was severe enough to

burst some blood vessels and leak blood into the skin; a bruise; an injury of a part without a break in the

skin.

cerebral cortical contusion: a bruising and bleeding on the brain’s surface from traumatically

injured cortical vessels; generally but not always associated with loss of consciousness; may be

small or large, single or multiple, unilateral or bilateral; most frequent sites for contusion are the

frontal and temporal poles

coup contusion: occurs at the point of impact; produced by deformation and inbending

of bone at the point of impact

contrecoup contusion: a contusion occurring distant from the site of impact by

transmitted force; occurs predominately in the frontal and temporal poles.

myocardial contusion: contusion of the heart, most frequently due to impact against an

automobile steering wheel or other blunt object; the trauma may cause arrhythmias, conduction

disturbances or clinical signs of infarction such as electrocardiographic abnormalities. contusion

of spinal cord: organic injury to the cord due to a blow to the vertebral column, with resultant

transient or prolonged dysfunction below the level of the lesion; also called concussion of spinal

cord

Cranium: the skeleton of the head, variously construed as including all of the bones of the head, except

the mandible: or the eight bones which form the calvaria that lodges the brain.

Cystic duct: the passage connecting the neck of the gallbladder and the common bile duct; also called

duct of gallbladder.

D

Decerebration: a type of abnormal motor movement reflecting brainstem dysfunction, seen in some

comatose patients and characterized by abnormal rigid extension of the extremities. Can occur

spontaneously or be induced by noxious stimuli. May be observed in one or all four extremities. Also

called posturing.

Decortication: a type of abnormal motor movement reflecting cerebral dysfunction, seen in some

comatose patients and characterized by abnormal flexion of the upper extremities. Can occur

spontaneously or be induced by noxious stimuli. May be observed in one or both upper extremities. In

classic decortication, extension of the lower extremities accompanies the upper extremity flexion. Also

called posturing

Degloving: The tearing away and detachment of skin and neurovascular structures from the bone. It is

usually more extensive than an avulsion injury.

Deviated trachea: usually means one lung is overexpanded or the other lung has collapsed

Diaphragm: the musculomembranous partition separating the abdominal and thoracic cavities and

serving as a major inspiratory muscle.


Page 111

Diaphyseal: pertaining to or affecting the shaft of a long bone.

Diastasis: a form of dislocation in which there is separation of two bones normally attached to each other

without the existence of a true joint; as in separation of the pubic symphysis. Also, separation beyond the

normal between associated bones, as between the ribs, or the ulna and radius.

Dislocation: the displacement of any part, more especially of a bone; called also luxation.

Dissecting: To slip between tissue layers, separating the layers instead of destroying them, e.g., dissection

between the layers of an arterial wall by blood leaking into the arterial wall. The danger of arterial

dissection is acute obstruction of the artery itself or of a major branch off the artery.

Distal: a comparative term indicating a point, structure or location further from the root or attachment

point (e.g., the knee joint is distal to the hip).

Duodenum: the first or proximal portion of the small intestine, extending from the pylorus to the

jejunum; so called because it is about 12 finger breadths in length.

Dura: outermost, toughest and most fibrous of the three membranes covering the brain and spinal cord;

also called dura mater.

E

Edema: presence of abnormally large amounts of fluid in the body tissue.

Epiphysis: the terminal ends of long bones.

Esophagus: the upper part of the alimentary tract, extending from the pharynx to the stomach.

F

Falx: a general anatomical term for a sickle-shaped organ or structure

falx of cerebellum (falx cerebelli): the small fold of dura mater in the midline of the

posterior cranial fossa, projecting forward toward the vermis of the cerebellum.

falx of cerebrum (falx cerebri): the sickle-shaped fold of dura mater that extends

downward in the longitudinal cerebral fissure and separates the two cerebral hemispheres.

Femur: (thigh bone) the bone that extends from the pelvis to the knee; the longest and largest bone in the

body. Its head articulates with the acetabulum of the hip bone; distally the femur, along with the patella

and tibia, forms the knee joint.

Fibula: the outer and smaller of the two bones of the leg, which articulates proximally with the tibia and

distally is joined to the tibia.

Flail: exhibiting abnormal or paradoxical movement, such as flail joint, flail chest or flail valve

Flail chest: one whose wall moves paradoxically with respiration, owing to multiple fractures of the ribs;

if a rib is fractured in two places, the free-floating piece may be sucked into the thorax with each

inspiration, preventing expansion of that section of the lung.

Flank: the fleshy part of the side between the ribs and the hip

Fossa: a trench or channel; a general term for a hollow or depressed area.

Cerebellar fossa: either of a pair of depressions in the occipital bone posterior to the foramen

magnum, separated from one another by the internal occipital crest, that lodge the hemispheres of

the cerebellum

Cerebral fossa: either of a pair of depressions in the occipital bone, posterior to the cerebellar

fossae, that house the occipital lobes of the cerebrum.

Anterior cranial fossa: the anterior subdivision of the floor of the cranial cavity, housing the

frontal lobes of the brain, and composed of portions of three bones: the ethmoid, frontal and

sphenoid.

Middle cranial fossa: the middle subdivision of the floor of the cranial cavity, supporting the

temporal lobes of the brain and the pituitary gland; it is composed of the body and greater wings

of the sphenoid bone and the squamous and petrous portions of the temporal bone.

Posterior cranial fossa: the posterior subdivision of the floor of the cranial cavity, housing the

cerebellum, pons and medulla oblongata; it is formed by portions of the sphenoid, temporal,

parietal and occipital bones.

Fracture: the breaking of a part, especially a bone.

Annular basilar fracture: see ring fracture


Page 112

Articular fracture: a fracture of the joint surface of a bone; also called joint fracture.

Avulsion fracture: an indirect fracture caused by avulsion or pull of a ligament.

Axial compression fracture: fracture of a vertebra by excessive vertical force, so that

pieces of it move out in horizontal directions, often injuring the spinal cord; it usually

occurs in the thoracic or lumbar region as a result of flexion. Also called burst fracture.

Barton's fracture: fracture of the distal end of the radius into the wrist joint.

Basal neck fracture: fracture of the neck of the femur at its junction with the trochanteric

region.

Bennett's fracture: a fracture of the base of the first metacarpal bone running into the

carpometacarpal joint and complicated by subluxation.

Blow-out fracture: fracture of the orbital floor caused by a sudden increase of intraorbital

pressure due to traumatic force; the orbital contents herniate into the maxillary sinus so that the

inferior rectus or inferior oblique muscle may become incarcerated in the fracture site, producing

diplopia on looking up. In the pure type there is disruption of the orbital floor without

involvement of the orbital rim; the impure type involves the rim, i.e., there is concomitant

midfacial fracture.

Burst fracture: axial compression fracture.

Bursting fracture: a comminuted fracture of the distal phalanx; called also tuft fracture.

Butterfly fracture: a comminuted fracture in which there are two fragments on each side of a

main fragment, somewhat resembling the wings of a butterfly.

Buttonhole fracture: fracture in which the bone is perforated by a missile; also called

perforating fracture.

Capillary fracture: a fracture that appears in the radiograph as a fine hairlike line, the

segments of bone not being separated; sometimes seen in fractures of the skull.

Chance fracture: horizontal splitting of the neural arch and body of a vertebra, usually in the

lumbar region, caused by a flexion-distraction force; also called seat belt fracture.

Chisel fracture: oblique detachment of a piece from the head of the radius.

Closed fracture a fracture which does not produce an open wound in the skin; also called simple

fracture.

Colles' fracture fracture of the lower end of the radius in which the lower fragment is

displaced posteriorly. Also called silver fork fracture. If the lower fragment is displaced

anteriorly, it is a reverse Colles' fracture (Smith's fracture).

Comminuted fracture: one in which the bone is splintered or crushed.

Complete fracture: one in which the bone is entirely broken across.

Complicated fracture: fracture with injury of the adjacent parts.

Compound fracture: open fracture (in AIS, except in the skull).

Compression fracture: one produced by compression, as of a vertebra; see also axial

compression fracture.

Condylar fracture: fracture of the humerus in which a small fragment including the

condyle is separated from the inner or outer aspect of the bone.

Contrecoup Fracture: a fracture of the skull opposite to the site of impact.

Coup fracture: a fracture at the point of injury.

Displaced fracture: break in a bone that causes one segment to be moved out of its normal

anatomical relation with the remainder of the bone.

Depressed skull fracture: a fracture in which a fragment is pushed down toward the brain.

Double fracture: see segmental fracture.

Dupuytren's fracture: 1. Pott's fracture. 2. (of forearm) Galeazzi's fracture.

Duverney's fracture: fracture of the ilium just below the anterior superior spine.

Fracture dislocation: fracture of a bone near an articulation with concomitant dislocation of that

joint.

Fracture en coin: (ah kwahn), a V-shaped fracture.

Fracture en rave (ah rahv), a fracture in which the break is transverse at the surface, but not

within.

Epiphyseal fracture: fracture at the point of union of an epiphysis with the shaft of a bone.


Page 113

Extracapsular fracture: a fracture of the humerus or femur outside of the capsule.

Fissure fracture, fissured fracture: a crack extending from a surface into, but not through, a

long bone.

Fracture of the liver: sometimes used to describe laceration of the liver

Galeazzi's fracture: fracture of the radius above the wrist combined with dislocation of the

distal end of the ulna; called also Dupuytren's fracture.

Gosselin's fracture: a V-shaped fracture of the distal end of the tibia, extending into the ankle

joint.

Greenstick fracture: fracture in which one side of a bone is broken, the other being bent; also

called hickory-stick or willow fracture.

Guérin's fracture: Le Fort I fracture

Gutter fracture: a fracture of the skull in which the depression is long and elliptic in form; often

caused by a missile passing along the outside or grooving the inside of the skull.

Hangman's fracture: fracture through the pedicles of the axis (C2) with or without subluxation

of the second cervical vertebra on the third.

Hickory-stick fracture: see greenstick fracture.

Horizontal maxillary fracture: Le Fort I

Impacted fracture: fracture in which one fragment is firmly driven into the other.

Incomplete fracture: one which does not entirely destroy the continuity of the bone.

Jefferson's fracture: fracture of the atlas (first cervical vertebra).

Joint fracture: articular fracture.

Jones fracture: diaphyseal fracture of the fifth metatarsal.

Le Fort's fracture: bilateral horizontal fracture of the maxilla. Le Fort fractures are classified as

follows: Le Fort I , a horizontal segmented fracture of the alveolar process of the maxilla, in

which the teeth are usually contained in the detached portion of the bone; called also Guérin's

fracture and horizontal maxillary fracture. Le Fort II, unilateral or bilateral fracture of the

maxilla, in which the body of the maxilla is separated from the facial skeleton and the separated

portion is pyramidal in shape; the fracture may extend through the body of the maxilla down the

midline of the hard palate, through the floor of the orbit, and into the nasal cavity. Called also

pyramidal fracture. Le Fort III, a fracture in which the entire maxilla and one or more facial

bones are completely separated from the craniofacial skeleton; such fractures are almost always

accompanied by multiple fractures of the facial bones. Called also craniofacial disjunction and

transverse facial fracture.

Linear fracture: a fracture extending along the length of a bone.

Monteggia's fracture: fracture in the proximal half of the shaft of the ulna, with dislocation of

the head of the radius. Sometimes called parry fracture because it is often caused by attempts to

fend off blows with the forearm.

Moore's fracture: fracture of the lower end of the radius with dislocation of the head of the ulna

and imprisonment of the styloid process beneath the annular ligaments.

Multiple fracture: a variety in which there are two or more lines of fracture of the same bone

not communicating with each other.

Oblique fracture: a fracture that transverses the shaft at an angle.

Open fracture: one in which there is an external wound leading to the break of the bone; called

also compound fracture.

Paratrooper fracture: fracture of the posterior articular margin of the tibia and / or of the

internal or external malleolus.

Perforating fracture: buttonhole fracture.

Periarticular fracture: a fracture extending close to, but not into, a joint.

Pertrochanteric fracture: fracture of the femur passing through the great trochanter.

Pillion fracture: a fracture of the lower end of the femur occurring when the knee of a person

riding pillion on a motorcycle is struck in a collision; it is a T-shaped fracture with displacement

of the condyles behind the femoral shaft.

Pilon fracture: intra-articular fracture of the distal end of the tibia that occurs as a result of the

talus being pushed upward into the tibial plafond.


Page 114

Ping-pong fracture: a type of depressed skull fracture usually seen in young children,

resembling the indentation that can be produced with the finger in a ping-pong ball; when

elevated it resumes and retains its normal position. Called also pond fracture.

Pott's fracture: fracture of the lower part of the fibula, with serious injury of the lower tibial

articulation, usually a chipping off of a portion of the medial malleolus, or rupture of the medial

ligament; called also Dupuytren's fracture.

Pyramidal fracture: (of maxilla) Le Fort II

Resecting fracture: a fracture in which a piece of the bone is removed by violence, as by a

bullet.

Ring fracture: a fracture in the base of the skull in the area surrounding the foramen magnum,

also called annular basilar fracture

Sagittal slice fracture: fracture of a vertebra breaking it in an oblique direction; the spinal

column above is displaced horizontally, usually causing paraplegia.

Seat belt fracture: Chance fracture.

Segmental fracture: fracture of a bone in two places.

Shepherd's fracture: fracture of the astragalus, with detachment of the outer protecting edge.

Silver-fork fracture: see Colles' fracture.

Simple fracture: closed fracture.

Simple fracture, complex: a closed fracture in which there is considerable injury to adjacent

soft tissues.

Skillern's fracture: complete fracture of the lower third of the radius with greenstick fracture of

the lower third of the ulna.

Smith's fracture: a fracture of the lower end of the radius near its articular surface with forward

displacement of the lower fragment; sometimes called reverse Colles' fracture.

Spiral fracture: one in which the bone has been twisted apart; called also torsion fracture.

Splintered fracture: a comminuted fracture in which the bone is splintered into thin, sharp

fragments.

Sprain fracture: the separation of a tendon or ligament from its insertion, taking with it a piece

of bone.

Sprinter's fracture: fracture of the anterior superior or of the anterior inferior spine of the ilium,

a fragment of the bone being pulled off by muscular violence, as at the start of a sprint.

Stellate fracture: a fracture with a central point of injury, from which radiate numerous fissures.

Stieda's fracture: fracture of the internal condyle of the femur.

Subcapital fracture: fracture of a bone just below its head; especially an intracapsular fracture

of the neck of the femur at the junction of the head and neck.

Subperiosteal fracture: a crack through a bone without alteration in its alignment or contour,

the supposition being that the periosteum is not broken.

Supracondylar fracture: fracture of the humerus in which the line of fracture is through the

lower end of the shaft of the humerus.

Torsion fracture: spiral fracture.

Transcervical fracture: fracture through the neck of the femur.

Transcondylar fracture: fracture of the humerus in which the line of fracture is at the level of

the condyles, traverses the fossae, and is in part within the capsule of the joint; called also

diacondylar fracture.

Transverse fracture: a fracture at right angles to the axis of the bone.

Transverse facial fracture: Le Fort III

Transverse maxillary fracture: a term sometimes used for horizontal maxillary fracture (Le

Fort I ).

Trimalleolar fracture: fracture of the medial and lateral malleoli and the posterior tip of the

tibia.

Tuft fracture: bursting fracture.

Undisplaced fracture: break in a bone that does not cause the bone to be moved out of its

normal anatomical position.

Vault fracture: fracture of the skull, also called a simple or linear fracture.


Page 115

Wagstaffe's fracture: separation of the internal malleolus.

Wedge-compression fracture: compression fracture of only the anterior part of a vertebra,

leaving a wedge-shaped vertebra.

Willow fracture: see greenstick fracture.

Fracture-dislocation: a fracture of a bone near a joint, also involving dislocation.

Friction burns: brush burns; caused by rubbing.

G

Gallbladder: the pear-shaped reservoir for the bile on the postero-inferior surface of the liver, between

the right and the quadrate lobe; from its neck, the cystic duct projects to join the common bile duct.

Gluteus: refers to the buttocks.

H

Hematoma: a localized collection of blood, usually clotted, in an organ, space or tissue, due to a break in

the wall of a blood vessel.

Epidural hematoma: accumulation of blood in the epidural space, due to damage to and leakage

of blood from the middle meningeal artery, producing compression of the dura mater and thus

compression of the brain. Unless evacuated, it may result in herniation through the tentorium, and

death. Often associated with a vault or linear skull fracture of the temporal skull bone.

Subdural hematoma: accumulation of blood in the subdural space. In the severe acute form,

both blood and cerebrospinal fluid enter the space as a result of laceration of the brain and a tear

in the arachnoid, adding subdural compression to the direct injury to the brain. The acute subdural

hematoma is the result of a traumatic event and is often associated with brain swelling and

increased intracranial pressure (ICP). In the chronic form, only blood effuses into the subdural

space as a result of rupture of the bridging veins. The chronic subdural may also result from

trauma but, unlike the acute subdural, the symptoms are less acute and the deficits are usually less

severe. The effusion of blood with a chronic subdural is a more gradual process with symptom

onset appearing days, weeks or even months after the injury. Most commonly occurs in the

elderly.

Intracerebral hematoma: a well-defined homogeneous collection of blood deep within

the brain parenchyma that may be as small as 1 mm or large enough to involve several

lobes of the brain; most frequent sites are the frontal and temporal lobes.

Hemiparesis: a slight paralysis on one side of the body.

Hemiplegia: paralysis on one side of the body.

Hemomediastinum: a collection of blood around the structures (heart, esophagus, etc.) between the two

pleural sacs that line the thoracic cavity and encase the lungs.

Hemothorax: a collection of blood in the pleural portions of the thoracic (chest) cavity.

Hemotympanum: a hemorrhagic exudation into the middle ear.

Hemorrhage: the escape of blood from the vessels; bleeding. Small hemorrhages are classified according

to size as petechiae (very small), purpura (up to 1 cm), and ecchymoses (larger). The massive

accumulation of blood within a tissue is called a hematoma.

extradural hemorrhage: intracranial hemorrhage into the epidural space.

internal hemorrhage: hemorrhage in which the extravasated blood remains within the body.

intracerebral hemorrhage: hemorrhage within the cerebrum.

intracranial hemorrhage: bleeding within the cranium, which may be extradural, subdural,

subarachnoid or cerebral

intraventricular hemorrhage: blood within the ventricles; strongly suggests a severe

brain injury

punctate hemorrhage: spots of blood effused into the tissues from capillary hemorrhage.

subarachnoid hemorrhage: intracranial hemorrhage into the subarachnoid space; frequently

associated with intracranial hematoma; most common cause is trauma.

subdural hemorrhage: cerebral hemorrhage into the subdural space

Hemopneumothorax: pneumothorax with hemorrhagic effusion.


Page 116

Hepatic duct, common: the duct which is formed by union of the right and left hepatic ducts, and in turn

joins the cystic duct to form the common bile duct.

Hepatic duct, left: the duct that drains the left and quadrate lobes and part of the caudate lobe of the

liver.

Hepatic duct, right: the duct that drains the right lobe and part of the caudate lobe of the liver.

Herniation: the abnormal protrusion of an organ or other body structure through a defect or natural

opening in a covering, membrane, muscle or bone.

Cerebral herniation: protrusion of the brain substance through the skull, through either the

foramen magnum or the tentorial notch.

Tentorial herniation: downward displacement of the most medially-placed cerebral structures

through the tentorial notch, caused by a supratentorial mass. Pressure is exerted on underlying

structures, including the brain stem. Also called caudal transtentorial herniation, transtentorial

herniation, and uncal herniation.

Tonsillar herniation: protrusion of the cerebellar tonsils through the foramen magnum, exerting

pressure on the medulla oblongata.

Hilum: a general term for a depression or pit at that part of an organ where the vessels and nerves enter

Hilum of kidney: the point on the medial margin of the kidney where the vessels, nerves and ureter

enter.

Hilum of spleen: the fissure on the gastric surface of the spleen where the vessels and nerves enter; also

called hilum lienis

Hygroma: accumulation of extravasated serous fluid in the extradural space; occasionally seen as a

chronic sequelae of cerebral contusions, particularly with frontal lobe contusions.

Hygroma, subdural: an abnormal collection of cerebrospinal fluid in a subdural location, thought to

occur from a tear of the arachnoid, allowing communication between the subarachnoid and subdural

space. Generally a non-acute lesion; often seen as a sequelae of frontal lobe contusions

Hyoid bone: a horseshoe-shaped bone situated at the base of the tongue, just superior to the thyroid

cartilage

Hypalgesia: decreased sensitivity to pain

Hypesthesia: abnormally decreased sensitivity, particularly to touch. Called also hypoesthesia

I

Iatrogenic: induced inadvertently by a physician or his / her treatment or procedure, e.g., a pneumothorax

can result during placement of an intravenous line into the subclavian vein.

Ileum: lower portion of the small intestine, extending from the jejunum to the large intestine.

Inferior sagittal sinus: one of the sinuses of the dura mater; situated in the posterior half of the lower

concave border of the cerebral falx, and opens into the upper end of the straight sinus.

Infarction, cerebral: an ischemic condition of the brain, producing a persistent focal neurological deficit

in the area of one of the cerebral arteries.

Inguinal: refers to region of the groin.

Interstitial emphysema: the escape of air into the connective tissue of the lung, mediastinum or

subcutaneous tissue resulting from a tear or rupture of the respiratory passages or alveoli, which may

occur in association with bronchiolar obstruction or be caused by a penetrating wound of the chest wall or

the lung.

Intestine, large: the distal portion of the intestine, about five feet long, extending from its junction with

the small intestine to the anus; comprises the cecum, colon, rectum and anal canal.

Intestine, small: the proximal portion of the intestine, smaller in caliber than the large intestine, and

about twenty feet long, extending from the pylorus to the cecum; comprises the duodenum, jejunum and

ileum.

Intima: a general term denoting an innermost structure; pertaining to the inner layer of the blood vessels.

Ischemia: localized decrease in the flow of blood usually due to an arterial obstruction.


Page 117

Ischium, greater incisure of: the large notch on the posterior border of the hip bone, where the posterior

borders of the ilium and the ischium become continuous. Also called greater ischial incisure or notch,

greater notch of ischium, greater sciatic notch, and incisura ischialis major

Ischium, lesser incisure of: the notch on the posterior border of the ischium just inferior to the ischiadic

spine. Also called incisura ischialis minor, lesser ischial incisure or notch, lesser notch of ischium, and

lesser sciatic notch.

J

Jejunum: the upper portion of the small intestine which extends from the duodenum to the ileum.

Jugular: refers to veins in the neck, draining the head.

K

Kidney: either of the two organs in the lumbar region that filter the blood and excrete the end-products of

body metabolism in the form of urine. Each human kidney is about 11 cm long, 5-7.5 cm wide, and 2.5

cm thick, and weighs from 120-160 gm. The kidney has a notch on the inner concave border, known as

the hilus, which communicates with the cavity or sinus of the kidney and through which the vessels,

nerves and ureter pass. The kidney consists of a cortex and a medulla.

L

Laceration: a tear or shear in the skin from a blunt or penetrating force (a cut or open wound).

Lamina papyracea: a portion of the medial orbital wall

Liver: a large gland of a dark-red color situated in the upper part of the abdomen on the right side. Its

domed upper surface fits closely against and is adherent to the inferior surface of the right diaphragmatic

dome, and it has a double blood supply from the hepatic artery and the portal vein. It comprises thousands

of minute lobules, the functional units of the liver

M

Malleolus, lateral: the rounded protuberance on the lateral surface of the ankle joint, produced by the

lateral malleolus of fibula.

Malleolus, lateral, of fibula: the process at the outer side of the lower end of the fibula, forming, with

the medial malleolus tibiae, the mortise in which the talus articulates.

Malleolus, medial: the rounded protuberance on the medial surface of the ankle joint, produced by the

medial malleolus tibia.

Malleolus, medial, of tibia: the process at the inner side of the lower end of the tibia, forming, with the

lateral malleolus of fibula, the mortise in which the talus articulates.

Mandible: the bone of the lower jaw; the horseshoe-shaped bone forming the lower jaw; the largest and

strongest bone of the face, presenting a body and a pair of rami, which articulate with the skull at the

temporomandibular joints.

Manubrium: superior part of the sternum.

Maxilla: the irregularly shaped bone that with its fellow forms the upper jaw; it assists in the formation of

the orbit, the nasal cavity and the palate, and lodges the upper teeth.

Mediastinum: the mass of tissues and organs separating the two pleural sacs, between the sternum

anteriorly and the vertebral column posteriorly and from the thoracic inlet superiorly to the diaphragm

inferiorly. It contains the heart and its pericardium, the bases of the great vessels, the trachea and bronchi,

esophagus, thymus, lymph nodes, thoracic duct, phrenic and vagus nerves and other structures and

tissues. The mediastinum is divided into a superior region and an inferior region that comprises anterior,

middle and posterior parts.

Meninges: membranous coverings of the brain and spinal cord. The three membranes are the dura

(outer), the arachnoid (middle), and the pia (inner). The dura is often lacerated or torn in traumatic brain

injuries such as a depressed or basilar skull fracture, thus allowing the escape of cerebrospinal fluid from

the subarachnoid space.


Page 118

Mesentery: a membranous fold attaching various organs to the body wall. Commonly used with specific

reference to the peritoneal fold attaching the small intestine to the dorsal body wall.

Metacarpal: refers to bones between the wrist and fingers.

Metatarsal: refers to bones of the foot between the tarsal bones and the toes.

Muscle belly: the fleshy, contractile part of a muscle

N

Necrosis: death of a cell or tissue

O

Occlusion: see Thrombosis.

Omentum: a fold of peritoneum extending from the stomach to adjacent organs in the abdominal cavity.

Omentum major, greater omentum: a prominent peritoneal fold suspended from the greater curvature

of the stomach and passing inferiorly a variable distance in front of the intestines; it is attached to the

anterior surface of the transverse colon.

Omentum minor, lesser omentum: a peritoneal fold joining the lesser curvature of the stomach and the

first part of the duodenum to the porta hepatis.

Ossicular chain: ear bone comprised of three small bones (malleus, incus, and stapes) between the outer

ear (pinna) and inner ear.

Otorrhea: a discharge from the ear, sometimes purulent (could involve CSF in skull fracture).

P

Pancreas: a large, elongated, racemose gland situated transversely behind the stomach, between the

spleen and the duodenum. Its right extremity, the head (caput) is the larger, and directed downward; the

left extremity, or tail (cauda), is transverse and terminates close to the spleen. It is subdivided into lobules

by septa that extend down into the gland from the thin, areolar tissue that forms an indefinite capsule.

Paraplegia: paralysis confined to the lower limbs

Paresis: slight or incomplete paralysis; weakness

Paresthesia: an abnormal touch sensation, such as burning, prickling, numbness and tingling often in the

absence of an external stimulus.

Pars interarticularis: a component of the vertebral lamina.

Pelvic hematoma: a collection of blood in the pelvic cellular tissue.

Pelvis: the inferior portion of the trunk of the body, bounded anteriorly and laterally by the two hip bones

and posteriorly by the sacrum and coccyx. The pelvis is divided by a plane passing through the terminal

lines into the false pelvis (pelvis major) superiorly and the true pelvis (pelvis minor) inferiorly. The

superior boundary of the cavity of the pelvis is known as the inlet, brim or superior strait of the pelvis.

The true pelvis is limited inferiorly by the inferior strait, or outlet, bounded by the coccyx, the symphysis

pubis and the ischium of either side.

Penetrating injury (as used in AIS coding): injury resulting from a gunshot or stab wound or from

impalement or spearing type trauma, with or without injury to the underlying organs or structures.

Perforation: a hole through an organ or other body structure resulting from contact with an external force

or object.

Pericardium: the fibroserous sac that surrounds the heart and the roots of the great vessels, comprising

an external layer of fibrous tissue and an inner serous layer. The base of the pericardium is attached to the

central tendon of the diaphragm.

Peritoneal cavity: the potential space between the visceral and the parietal peritoneum; it consists of the

pelvic peritoneal cavity below and the general peritoneal cavity above. The general peritoneal cavity

communicates with the cavity of the greater omentum, which is also known as the lesser peritoneal cavity.


Page 119

Peritoneum, visceral: a continuation of the parietal peritoneum reflected at various places over the

viscera, forming a complete covering for the stomach, spleen, liver, ascending portion of the duodenum,

jejunum, ileum, transverse colon, sigmoid flexure, upper end of rectum, uterus and ovaries. It also

partially covers the descending and transverse portions of the duodenum, the cecum, ascending and

descending colon, the middle part of the rectum, the posterior wall of the bladder, and the upper portion

of the vagina. The peritoneum serves to hold the viscera in position by its folds, some of which form the

mesenteries, connecting portions of the intestine with the posterior abdominal wall; other folds, the

omenta, are attached to the stomach; and still others form the ligaments of the liver, spleen, stomach,

kidneys, bladder and uterus.

Petechiae: tiny leakage of blood from burst capillaries.

Pharynx: proximal end of the digestive throat into which the oral and nasal cavities empty.

Pituitary: a gland located at the base of the brain in the sella turcica.

Pleura: the serous membrane investing the lungs and lining the thoracic cavity, completely enclosing a

potential space known as the pleural cavity. There are two pleurae, right and left, entirely distinct from

each other. The pleura is moistened with a serous secretion which facilitates the movements of the lungs

in the chest.

Plexus: a network of nerves

Pneumocephalus: air in the intracranial cavity

Pneumomediastinum: the presence of air or gas in the mediastinum, which may interfere with

respiration and circulation, and may lead to such conditions as pneumothorax or pneumopericardium. It

may occur spontaneously or as a result of trauma or a pathologic process, or it may be induced

deliberately as a diagnostic procedure. Called also Hamman's syndrome and mediastinal emphysema.

Pneumothorax: an accumulation of air or gas in the pleural space, which may occur spontaneously or as

a result of trauma or a pathological process, or be introduced deliberately; can also be introduced

accidentally during a medical procedure (iatrogenic). Rupture of a lung alveolus or puncture of the chest

wall allows air to penetrate the pleural space, disrupting the bond of surface tension between the two

pleurae. This causes an increase in air on that side of the chest with thoracic percussion producing a

hollow and resonant sound called tympany. The lung collapses leaving a large, empty, hyperresonant

hemithorax, called a pneumothorax. Conversely, blood in the pleural space is called a hemothorax, which

causes dullness to percussion.

Closed pneumothorax: pneumothorax in which pulmonary air leaks into the pleural cavity

through a wound in a lung.

Extrapleural pneumothorax: production of collapse of the lung by formation of an air pocket

by stripping the pleural layers from the inner surface of the ribs and intercostal muscle sheaths.

Open pneumothorax: pneumothorax in which the pleural cavity is exposed to the atmosphere

through an open wound in the chest wall.

Pressure pneumothorax: see tension pneumothorax.

Tension pneumothorax: closed pneumothorax in which the tissues surrounding the opening

into the pleural cavity act as valves, allowing air to enter but not to escape. The resultant positive

pressure in the cavity displaces the mediastinum to the opposite side, with consequent respiratory

difficulty. Also called pressure pneumothorax.

Pressure cone: the area of compression exerted by a mass in the brain, as in uncal or transtentorial

herniation.

Proptosis: Bulging eye; synonymous with exophthalmos

Proximal: a comparative term indicating a point, structure or location closer to the root of the limb (e.g.,

the hip joint is proximal to the knee).

Pubis, inferior ramus: the short flattened bar of bone that projects from the body of the pubic bone in a

posteroinferolateral direction to meet the ramus of the ischium.

Pubis, superior ramus: the bar of bone projecting from the body of the pubic bone in a

posterosuperolateral direction to the iliopubic eminence, and forming part of the acetabulum.

Puncture: a wound made by a pointed object.

Puncture, superficial: a perforation not into subcutaneous tissue, regardless of length or into

subcutaneous tissue but 10 cm or less on the face, head or hand, or 20 cm or less on the body.


Page 120

Q

Quadriplegia: paralysis of all four extremities; also called tetraplegia.

R

Retroperitoneum (retroperitoneal / extraperitoneal space): the space between the posterior parietal

peritoneum and the posterior abdominal wall, containing the kidneys, suprarenal glands, ureters,

duodenum, ascending and descending colon, pancreas, and the large vessels and nerves.

Rhinorrhea: a discharge of mucus from the nose (could involve CSF in skull fracture).

Rib: any one of the paired elastic arches of bone, twelve on either side, that extend from the thoracic

vertebrae toward the median line on the ventral aspect of the trunk, forming the major part of the thoracic

skeleton. The upper seven (true ribs) are connected ventrally with the sternum. The lower five (false ribs)

are not. Collectively called costae.

Rib, “cracked”: a partial fracture, one that does not break the bone through and through

Rupture: forcible tearing or breaking of a body structure (i.e., membrane, organ, tendon, etc).

S

Sacrum: the triangular bone just below the lumbar vertebrae, formed usually by five fused vertebrae

(sacral vertebrae) that are wedged dorsally between the two hip bones

Scalp: that part of the skin of the head, exclusive of the face and ears. Consists of 5 layers: skin,

subcutaneous tissue, galea, the subgaleal space and the pericranium or periosteum. Injuries range from

simple lacerations to total avulsions and may be associated with underlying bone, dura or brain injury.

Because of its vascular anatomy, even simple scalp lacerations can result in significant blood loss and

hypovolemic shock.

Segmental loss: a term used to indicate that a section of a vessel is gone (indicative of two lacerations);

segmental loss and transection are equivalent in severity.

Sigmoid sinus: either of two sinuses of the dura mater, continuations of the transverse sinuses that

subsequently become continuous with the internal jugular vein.

Sinus: a general term for such spaces as the dilated channels for venous blood in the cranium or liver, or

the air cavities in the cranial bones.

Sinus thrombosis: thrombosis of a sinus of the dura mater, usually secondary to head injury.

Skin: the outer integument or covering of the body, Consists of an outer superficial layer (epidermis), and

a deeper layer that contains blood vessels and fat (dermis); called also cutis.

Skull: the bony framework of the head, composed of the cranial bones and the bones of the face. It

includes the ethmoid, frontal, hyoid, lacrimal, nasal, occipital, palatine, parietal, sphenoid, temporal and

zygomatic bones, and the inferior nasal conchae, mandible, maxillae and vomer.

Spleen: a large gland-like but ductless organ situated in the upper part of the abdominal cavity on the left

side and lateral to the cardiac end of the stomach. It is of a flattened oblong shape and about 125 mm

long, the largest structure in the lymphoid system.

Sphenoid bone: a single, irregular, wedge-shaped bone at the base of the skull, which forms a part of the

floor of the anterior, middle and posterior cranial fossae; called also alar bone.

Spondylolisthesis: forward displacement of one vertebra over another.

Sprain: a joint injury in which some of the fibers of a supporting ligament are ruptured but the continuity

of the ligament remains intact.

Sternum: a longitudinal unpaired plate of bone forming the middle of the anterior wall of the thorax, and

articulating above with the clavicles and along the sides with the cartilages of the first seven ribs. It

consists of three portions: the manubrium, the body and the xiphoid process.

Strain: an overstretching or overexertion of a muscle; change in the size or shape of a body as the result

of an externally applied force.

Subarachnoid: situated beneath the middle membrane covering the brain and spinal cord.

Subcortical: situated beneath the gray matter or cortex of the brain.

Subcutaneous crepitus: Blebs of air under the skin. Usually seen when a lung leaks air into the

subcutaneous tissue.


Page 121

Subdural: situated beneath the outermost and most fibrous of the three membranes (dura) covering the

brain and spinal cord.

Subgaleal: beneath the scalp.

Subluxation: an incomplete or partial dislocation.

Subpial: situated beneath the pia mater.

Sucking wound: a penetrating wound of the chest wall through which air is drawn in and out.

Superior sagittal sinus: one of the sinuses of the dura mater; it begins in front of the crista galli, extends

backward in the convex border of the falx cerebri, and ends in the confluence of the sinuses. It receives

the superior cerebral veins and is partially invaginated by arachnoidal granulations.

Syringomyelia: a slowly progressive syndrome in which cavitation occurs in the central segments of the

spinal cord, generally involving the cervical region, but the lesions may extend up into the medulla or

down into the thoracic region; it may be of developmental origin, arise secondary to tumor, trauma,

infarction, or hemorrhage. It results in neurological deficits that generally consist of segmental muscular

weakness and atrophy accompanied by a dissociated sensory loss (loss of pain and temperature sensation,

with preservation of the sense of touch).

T

Talus: the highest of the tarsal bones and the one which articulates with the tibia and fibula to form the

ankle joint; called also ankle, ankle bone and astragalus

Tamponade, cardiac: acute compression of the heart due to effusion of fluid into the outer layer

(pericardium) of the heart or collection of blood in pericardium due to heart rupture or penetration.

Tension pneumothorax: closed pneumothorax in which the tissues surrounding the opening into the

pleural cavity act as valves, allowing air to enter the pleural space during inspiration, but prevent escape

of that air during expiration. Eventually, enough air accumulates in the pleural space to shove the lung to

the opposite side of the thorax, compressing the heart and the superior and inferior vena cava. The

immediate treatment is to make another sizable hole in the chest wall (with a large bore needle) to allow

the high intrathoracic pressure to escape.

Tetraplegia: see quadriplegia.

Thoracic cage: the skeletal framework enclosing the thorax, consisting of the thoracic vertebrae and

intervertebral disks, the ribs and costal cartilages, and the sternum.

Thoracic duct: the largest lymph channel in the body, which collects lymph from the portions of the

body below the diaphragm and from the left side of the body above the diaphragm; it begins in the

abdomen at about the level of the second lumbar vertebra and ends at the junction of the subclavian and

internal jugular veins.

Thorax: the part of the body between the neck and the diaphragm, encased by the ribs; the chest.

Thrombosis: the presence of a collection of blood components, primarily platelets and fibrin with

entrapment of cellular elements, frequently causing obstruction at the point of formation.

Trachea: the part of the air passage leading from the larynx to the bronchi.

Transverse sinus: either of two large sinuses of the dura mater that begin at the confluence of the sinuses

near the internal occipital protuberance.

V

Vena cava, inferior: the venous trunk for the lower extremities and for the pelvic and abdominal viscera;

it begins at the level of the fifth lumbar vertebra by union of the common iliac veins, passes upward on

the right of the aorta, and empties into the right atrium of the heart.

Vena cava, superior: the venous trunk draining blood from the head, neck, upper extremities and chest;

it begins by union of the two brachiocephalic veins and empties into the right atrium of the heart.

Ventricle: a cavity, especially in the heart and brain.

Vertebra: any of the 33 bones of the spinal column, comprising the 7 cervical, 12 thoracic,

5 lumbar, 5 sacral, and 4 coccygeal vertebrae.


Page 122

Vertebrae:

Cervical vertebrae: the upper seven vertebrae, constituting the skeleton of the neck. Symbols C1

through C7.

Thoracic vertebrae: the vertebrae, usually twelve in number, situated between the cervical and

the lumbar vertebrae, giving attachment to the ribs and forming part of the posterior wall of the

thorax. Symbols T1 through T12.

Lumbar vertebrae: the five vertebrae between the thoracic vertebrae and the sacrum.

Sacral vertebrae: the vertebrae below the lumbar vertebrae (usually five in number), which

normally fuse to form the sacrum. Symbol S1 through S5.

Coccygeal vertebrae: the lowest segments of the vertebral column, comprising three to five

rudimentary vertebrae which form the coccyx.

Z

Zygomatic process of temporal bone: a long, strong process arising from the inferior portion of the

squamous part of the temporal bone; joins the zygomatic bone and thus forms the zygomatic arch.


Page 123

BONES OF THE HUMAN SKELETON

NAME REGION DESCRIPTION

atlas neck 1st cervical vertebra, ring of bone supporting skull

axis neck 2nd

cervical vert, with thick process (odontoid) around which 1st

cervical vertebra pivots

calcaneus foot “heel bone”

capitate b. wrist with 2nd

, 3rd

, and 4th metacarpal b’s

carpal b’s wrist see capitate, hamate, lunate

clavicle shoulder elongated slender, curved bone (collar bone)

coccyx lower back triangular bone formed us. by fusion of last 4 vertebrae

concha, infer.nasal skull attached by one edge to side of each nasal cavity

cuboid b. foot on lateral side of foot, in front of calcaneus

cuneiform b.,

intermed.

foot smallest of 3 cuneiform bones

cuneiform b., lateral foot at lateral side of foot, in front of calcaneus

cuneiform b., medial foot largest of 3 cuneiform bones

ethmoid b. skull in front of sphenoid, forms part of nasal septum

fabella knee in lateral head of gastrocnemius muscle

femur thigh longest, strongest, heaviest bone of the body (thigh b)

fibula leg lateral and smaller of 2 bones of leg

frontal b. skull unpaired bone constituting anterior part of skull

hamate b. wrist most medial of 4 bones of distal row of carpal b’s

hip b. pelvis & hip broadest bone, composed of 3 fused bones: ilium, ischium, and pubis

humerus arm long bone of upper arm

hyoid b. neck at root of tongue, between mandible and larynx

ilium pelvis see hip b.


Page 124


incus ear middle ossicle of chain in the middle ear

innominate b. see hip b.

ischium pelvis see hip b.

lacrimal b. skull thin, uneven scale of bone near rim of medial wall of each orbit

lunate b. wrist 2nd

from thumb side of 4 boxes of proximal row of carpus

malleus ear most lateral ossicle of chain in middle ear, resembles hammer

mandible lower jaw horseshoe-shaped bone carrying lower teeth

maxilla skull paired bone, below orbit & at either side of nasal cavity, carrying

upper teeth

maxilla, inferior see mandible

maxilla, superior see maxilla

metacarpal b’s hand 5 miniature long bones of hand proper

metatarsal b’s foot 5 miniature long bones of foot

multiangulum majus see trapezium; trapezoid b.

nasal b. skull paired bone, the 2 uniting to form bridge of nose

navicular b. foot at medial side of tarsus, between talus and cuneiform b’s

occipital b. skull unpaired bone constituting back and part of base of skull

os magnum see capitate b.

palatine b. skull paired bone, the two forming posterior portions of bony palate

parietal b. skull paired bone between front & occipital b’s

patella knee small bone over anterior aspect of knee (kneecap)

phalanges finger & toes tiny long bones, 2 in thumb/great toe; 3 in other fingers & toes

pisiform b. wrist medial and palmar of 4 bones of proximal row of carpal b’s

pubic b. pelvis see hip b.

radius forearm lateral and shorter of 2 bones of forearm


Page 125


ribs chest 12 pairs of thin curved bones, forming post. & lat walls of chest

sacrum lower back formed by fusion of 5 vertebrae, below lumbar vertebrae, constituting

posterior wall of pelvis

scaphoid wrist most lateral of 4 bones of proximal row of carpal b’s

scapula shoulder opposite 2nd

to 7th ribs in upper part of back (shoulder blade)

sesamoid b’s hands & feet small flat bones related to joints between phalanges or digits and

metacarpal or metatarsal b’s; include also 2 at knee

sphenoid b’s base of skull unpaired, incl. part of sides & base of skull & part of lateral wall of

orbit

stapes ear most medial ossicle of chain in middle ear (resembles stirrup)

sternum chest elongated, flat, forming anterior wall of chest; 3 segments:

manubrium, body, and xiphoid process

talus ankle the “ankle bone”; second largest of tarsal bones

tarsal b’s ankle & foot see calcaneus, cuboid intermed., lat & med. cuneiforms, & talus

temporal b. skull one on either side, forms part of side and base of skull, contains

middle and inner ear

tibia leg medial and larger of 2 bones of lower leg (shin b.)

trapezium wrist most lateral of 4 bones of distal row of carpal b’s

trapezoid b. wrist 2nd

from thumb side of 4 bones of distal row of carpal b’s

triquetral b. wrist 3rd

from thumb side of 4 bones of proximal row of carpal b’s

turbinate b., inferior see concha, inferior nasal

ulna forearm medial and longer of 2 bones of forearm

vertebrae (cervical,

thoracic [dorsal],

lumbar, sacral, and

coccygeal)

back separate segments of vertebral column; about 33 in the child;

uppermost 24 remain separate as true, movable vertebrae; the next 5

fuse to form the sacrum; the lowermost 3-5 fuse to form the coccyx

vomer skull forms posterior and posteroinferior part of nasal septum

zygoma skull forms hard part of cheek & lower, lat. portion of rim of orbits


Page 126

ABBREVIATIONS

Abbrev. Meaning

aa of each

AA auto accident

Abd abdomen, abdominal

abg arterial blood gases

abr abrasion

Ac acute

ad to

A.D. right ear

ad lib at liberty

Adm admit

AE above elbow

AK above knee

AM before noon

AMA against medical advice

Amb. ambulatory

ante before

ant anterior

AOB alcohol on breath

A & P antero-posterior, auscultation

and palpation, auscultation and

percussion

AP arterial pressure

AP & Lat anterior, posterior and lateral

(projection of x-ray)

AS left ear

ASIS anterior superior iliac spine

AU both ears

AV antrioventricular or

auriculoventricular

ax axillary

BAC blood alcohol concentration

BE below elbow

bil bilateral

BK below knee

B.M.R. basal metabolic rate

B.P. blood pressure

BS breath sounds, bowel sounds,

blood sugar

c with

CAT computerized axial

tomography

Cn _____ cervical vertebra

CC chief complaint

CBC complete blood count

CCU coronary care unit

chr chronic

CNS central nervous system

Abbrev. Meaning

c/o complaints of

comp compound

cont contusion

cor coronary

CPR cardiopulmonary resuscitation

CR cardiac rate

CSF cerebrospinal fluid

CTA clear to auscultation

CT scan computerized tomography

CVA cardiovascular accident

CVT central vertebra tenderness

CXR chest x-ray

D dorsal

Dn ____ dorsal (thoracic vertebra)

D/C discontinue; discharge

DL danger list

DOA dead on arrival

DOB date of birth

DT delirium tremens

D.T.R. deep tendon reflexes

Dx diagnosis

ECG electrocardiogram (also EKG)

ED emergency department

EEG electroencephalogram

EENT eyes, ears, nose and throat

e.g. example

EKG electrocardiogram (also ECG)

EMG electromyograph,

electromyogram

EOM extraocular movement

ER emergency room

Etiol etiology

ETOH alcohol

exam examination

ext extremities

FB foreign body

FH family history

FROM full range of motion

ft foot

F/U follow up

FUO fever unknown origin

Fx fracture

G.B. gall bladder

GCS Glasgow coma score

Gen A general anesthesia

G.I. gastrointestinal

GM grand mal


Page 126

Abbrev. Meaning

G.U. genito-urinary

Gyn. gynecology

h, H hour

HA headache

hb, hgb hemoglobin

HBP high blood pressure

HCT hematocrit

HEENT head, ears, eyes, nose and

throat

HR heart rate

Hosp hospital

H&P history of physical illness

ht heart, height

Hx history

ICP intracranial pressure

ICU intensive care unit

I & D incision and drainage

i.e. that is

IMP impression

inf inferior

IOP intraocular pressure

IQ intelligence quotient

I.V. intravenous

K.U.B. kidney, ureter, bladder

L lumbar

L , lt left

lac laceration

Ln _____ lumbar vertebra

lat lateral

LE lower extremity

Lg. large

LL lower lobe

LLE left lower extremity

LLL left lower lobe of lung

LLQ lower left quadrant

LOC loss of consciousness

LOM loss of motion

LPN licensed practical nurse

LRQ lower right quadrant

LS lumbosacral; liver and spleen

LSK liver, spleen, kidney

LS lumbosacral

LUE left upper extremity

LUQ left upper quadrant

M, m murmur

MAE moves all extremities

mand mandible

max maxilla

Abbrev. Meaning

MD muscular dystrophy

MP metaphalangeal

mod moderate

MRI magnetic resonance imaging

MS musculoskeletal

M, T masses, tenderness

MVA motor vehicle accident

NAD no acute distress

N.C. no complaints

Neuro Neurology

NFS not further specified

NKA no known allergies

NL normal

nml normal

NOS not otherwise specified

NSR normal sinus rhythm (heart)

N/V nausea, vomiting

OB obstetrics

O.D. right eye

OPD out patient department

Ophth Ophthalmology

OR operating room

Ortho Orthopedics

O.S. left eye

OU both eyes p post, after

P. pulse

PA pulmonary aorta

P & A palpation and auscultation,

percussion and auscultation

Path Pathology

P.E. physical exam

per through or by

per os by mouth

PERRLA pupils equal, round, react to

light, accommodate

PH past history

PM petit mal

PM post mortem

PM afternoon

PMD private medical doctor

PMH past medical history

po by mouth

post posterior

post-op postoperative

PR pulse rate

pre-op preoperative

prn according to circumstances as


Page 127

Abbrev. Meaning

needed

prog prognosis

pt patient

PTA post traumatic amnesia

PTA prior to admission

PTR pulse, temperature, respiration

Px prognosis

qd every day

qh, qih every hour

qt quiet

R. respiration

®, rt right

RLE right lower extremity

RLL right lower lobe

RLQ right lower quadrant

R/O rule out

ROM range of motion

RR regular rhythm (heart)

RUE right upper extremity

RUL right upper lobe

RUQ right upper quadrant

Rx prescription, treatment

s without

S sacral vertebra

SAH subarachnoid hemorrhage or

hematoma

SB small bowel

S.C. subcutaneous

semi half

Sm small

SOB shortness of breath

S/P status post

spont spontaneous

ss, ss half

stat. at once

subcu subcutaneous

temp, T. temperature

TLC total lung capacity

TM tympanic membrane

TMJ temporomandibular joint

Tn _____ thoracic vertebra

T.P.R. temperature, pulse, respiration

TX treatment

TX traction

UE upper extremity

UGI upper gastrointestinal

U & L upper and lower

ULQ upper lower quaderant

Abbrev. Meaning

unil unilateral

URD upper respiratory disease

URI upper respiratory infection

URQ upper right quadrant

vs versus

VS vital signs

VSS vital signs stable

VT ventricular tachycardia

WBC white blood count

WD well developed

W/F white female

W/M white male

WN well nourished

wt weight

w/o without

YO years old


Page 128

HOSPITAL SYMBOLS

Symbol Meaning

♀ female

♂ male

º degree

↑ increase

↓ decrease

< less than

> greater than

c with

s without

ss half

+ plus

x times (multiplication)

o no, none

- minus

θ negative; no murmurs

= equal

≠ not equal to

~ approximately

1º primary, first degree

2º secondary, second degree

3º tertiary, third degree

# pounds; fracture

Δ change


Page 129

WEIGHTS AND MEASURES

Symbol Meaning

C Celsius or Centigrade (temperature): C + 5/9 (F – 32)

cc cubic centimeter (volume): cm3; 1 ml = 1 cc

cm centimeter (length): 1/100 of a meter; cm = inch x 2.54

cm2 square centimeters (area): cm

2 = in

2 x 6.4516

F Fahrenheit (temperature): F = 9/5 (C) + 32

ft foot (length): 12 inches

g, gm gram (weight)

in inch (length)

in2 square inches (area)

kg kilogram (weight) : 1000 grams; kg = lb x 0.4536

l liter (volume) : 1000 cm3 or 1000 ml

lb, # pound (weight) : 16 ounces

m meter (length) : m = ft x 0.3048

mg milligram (weight) : 1/1000 of a gram

mm millimeter (length) : 1/1000 of a meter

oz ounce (weight) : 1/16 of a pound

yd yard (length) : 3 feet


Page 130

ANATOMY AND TERMINOLOGY Selected References

Textbooks: Gray’s Anatomy, Running Press, Philadelphia, PA Grant’s Atlas of Anatomy, Williams & Wlkins Co., Baltimore, MD Dorland’s Illustrated Medical Dictionary, W.B. Saunders Co., Philadelphia, PA Stedman’s Medical Dictionary, Williams & Wilkins Co., Baltimore, MD The CIBA Collection of Medical Illustrations, a series prepare by Frank H. Netter,

CIBA-GEIGY Corporation, 14 Henderson Drive, West Caldwell, NJ 07006 Electronic: The Virtual Hospital (www.vh.org/Providers/Providers.html) The Bobby R. Alford Department of Otorhinolaryngology and Communicative

Sciences (www.bcm.tmc.edu/oto/studs)

For technical questions on the AIS and injury scaling: Kathy Cookman, AIS International Technical Coordinator Email: [email protected]

For your Monthly Frequently Asked Questions: www.aaam1.org/faq

For general inquiries: Association for the Advancement of Automotive Medicine 35 East Wacker Drive, Suite 850 Chicago, IL 60601-2106 USA Tel: 847-844-3880 Fax: 312-644-8557 Email: [email protected] AAAM Website: aaam.org

Reprint 2016

mailto:[email protected]

a specialized course on introducing the abbreviated injury

Documents