A Method Of Classifying, Coding And Organizing Amputee Data, Utilizing The "Standard Nomenclature Of Diseases And Operations"
Robert C. Hamilton, M.D.
A year ago, the necessity of developing an adequate card index system to be used for classifying and coding all of our amputees, both adult and juvenile, became apparent to us. Dr. Robert C. Hamilton, who is an Orthopaedic Surgeon in the Division of Services for Crippled Children, University of Illinois, assumed the burdensome assignment and subsequently evolved a punch card system which meets the requirements of coding and classifying amputees within the numerical system of the standard nomenclature. This system can be utilized without difficulty by any clinic that is using the standard nomenclature.
Several of the clinic chiefs and many others learned of this classification and discussed it with me at the January, 1963 meeting in Miami, Florida. They expressed a desire to use our method and said they would like to receive copies of the system. Due to the great interest shown, I thought that presentation of the classification in the Inter-Clinic Information Bulletin would be the fastest and surest way of providing this information to all interested parties. Dr. Hamilton's article follows:
Claude N. Lambert, M.D.
In our recent reorganization of the Amputee Clinic records, it became evident that an anatomic-etiologic code would be helpful in transferring the diagnostic data to IBM or Keysort (1) cards. The "Standard Nomenclature of Diseases and Operations" (2) was selected to serve as a basis for such a code. The basic principle guiding our approach to the task was that codes would not be radically changed, rather they would be modified by the addition of digits or decimals. For example, the majority of the code numbers used in Table 1 are taken directly from the standard nomenclature; those used in Table 2 are generally derived numbers to indicate "bones in combination", while Table 3 utilizes an extension of the standard nomenclature for the further clarification of etiology.
In classifying acquired amputations, the basic etiology was recorded, rather than secondary factors (as an example, a patient with an open fracture resulting from an automobile accident who later developed osteomyelitis, necessitating amputation, would be classified under vehicular trauma, rather than infection). In some of the older records, the basic etiology was not recorded; in this case, trauma was generally recorded and coded.
In the case of patients with congenital limb deficiencies, the classification of Frantz and 0'Rahilly (3) was utilized, adding only a subdivision for Hemimelia (for example, in the upper limb, a terminal transverse hemimelia could be either above or at the elbow; the significance, of course, being in the prosthetic implications), and a listing for PFFD - Proximal Femoral Focal Deficiency (see Table 4a and Table 4b ).
After the system of classification and coding was completed, our next step was to transfer the data to cards suitable for either mechanical or electronic sorting. The amount of recorded data was restricted in order to prevent the system from becoming cumbersome and losing its effectiveness. The cards were used as a guide for the investigator, rather than for the compilation of complete clinical information.
With a case load of approximately 1,400 amputees in our adult and juvenile clinics, it was decided that the Keysort (1) cards would adequately fulfill our requirements although electronically sorted cards are utilized for the Orthopaedic Clinic as a whole, since larger numbers of Keysort cards become difficult to handle.
The card, designed for general orthopaedic use, was modified for the purposes of our clinic. A card was made out for each amputation or deficiency (thus one patient may have several cards). The cards were punched and sorted according to the manufac-turer's instructions.
Information on Card
The following information was recorded on each card and the items marked with an asterisk (*) were punched for sorting:
Unit or Chart Number
*Date of Birth-only the last two digits of the year of birth are punched
*Diagnosis-etiologic and topographic
*Right, Left and/or Bilateral
*Juvenile or Adult
*Single or Multiple Amputations
*Conversion of Anomaly to Amputation; if the anomaly is a deficiency, it is coded separately
*Revision-for scars, overgrowth, etc.
*Reconstruction-as contrasted to revision is used to denote a procedure to increase function; e.g., pollicization of the second ray in an aphlangia
*Other Anomalies, not amputations; e. g., cleft palate
*Prosthetic Modification; e.g., nonstandard socket
*Alphabetical Sequence Number for finding a specific patient or realphabetizing after sorting
The manner in which the data were recorded and punched for children with acquired amputations and congenital skeletal deficien cies respectively can be noted by referring to Fig. 1 and Fig. 2 , sample cards. Thus item Number 3 above is punched on the right top of the card; Numbers 4 and 5 on the upper right side; Number 7, anatomic or topographic, at the bottom of the card on the right and etiologic at the bottom on the left; Numbers 8 through 16 on the lower left side; and Number 18, the Alphabetical Sequence Number, on the lower right side.
Number 7, anatomic or topographic and etiologic, the two major items recorded, require additional explanation. The anatomic coding numbers used are taken from System 0 (body as a whole) and System 2 (musculoskeletal system) of the standard nomenclature, with some extension of the latter system to encompass bones in combination. For example, 081 denotes arm and 235 indicates femur in Table 4a and Table 4b . Code number 23xxx, used to denote the phalanges of the feet in combination (Table 2 ), is an example of a derived number.
The etiologic coding numbers used are obtained from Category 0 (diseases due to genetic and prenatal influence) and Category 4 (diseases due to trauma or physical agent) of the standard nomenclature. Thus, in the congenital classifications, Oil - entire absence and 012 -partial absence, are the two series used (Table 4a and Table 4b ). The code numbers used for acquired amputations utilize the base series 405 (amputation) with an additional digit or decimal added to indicate the cause of the amputation (Table 3 ).
Since only three spaces are provided on the card for the etiologic diagnosis, the initial "4" was dropped for punching purposes. Moreover, because there was no provision on the card for the letter "x", by convention, both holes of the "1" and "2" spaces were punched for this letter (see [popuup1]). The foregoing modifications could be obviated by using cards made specifically for the Amputee Clinic.
Referring again to our first sample card (Fig. 1 ), it will be noted that the patient has a below-knee amputation resulting from a gunshot wound. The code for below-knee is 2x2 (Table 1 ), which is punched in the anatomic category at the right bottom of the card. The code for gunshot wound is 405x (Table 3 ), which is punched at the left bottom of the card in the etiologic category.
The same procedure of recording and punching is followed in the second sample card (Fig. 2 ). The code number, 084-011 (Table 4a and Table 4b ), indicates that the patient has been classified as a "partial hemimelia, upper limb". The number 084 is punched in the anatomic category and 011 in the etiologic category.
This system of recording and punching may appear to be complicated but, with some experience, is very simple. Those interested in securing additional information are advised to consult the sources cited in this article.
The above (Table 1 ) are to be followed by the appropriate etiologic (4---) code number.
Levels in long bones may be delineated further by the addition of the digits 1, 2, and 3 for the proximal, middle, and distal thirds, respectively.
We gratefully acknowledge the considerable assistance of Miss Jolene Nyberg, B.S. R.R.L., of the Medical Record Library, the University of Illinois, Research and Educational Hospitals, in the preparation of the system.
Keysort Punching and Sorting Manual, Royal McBee Corporation, Port Chester, N.Y.
Thompson, Edward T., Editor, "Standard Nomenclature of Diseases and Operations", McGraw-Hill Book Company, Inc., 1961.
Frantz, Charles H., and O'Rahilly, Ronan, "Congenital Skeletal Limb Deficiencies", Journal of Bone and Joint Surgery, 43-A, 1202, 1961.
Robert Hamilton is Instructor in Orthopaedic Surgery, University of Illinois