DAFTAR ISI

CLINICAL PATHWAY SMF ORTHOPAEDI & TRAUMATOLOGI

RSUD DR. SOETOMO SURABAYA

2013

Kode ICD-10 Halaman

General Orthopaedic
Fraktur - ................................................................1
Acute Septic Arthritis M00.9 ................................................................2
Arthritis Rheumatoid S52.1 ................................................................3
Arthritis Piogenik - ................................................................4
Crystal Deposition Disorders M10 ................................................................5
Deep Vein Thrombosis I82.4 ................................................................6
Distropi Muskuler G71.0 ................................................................7
Giant Cell Tumor of Tendon Sheath D.48 ................................................................8
Haemophilic Arthropathy S52.1 ................................................................9
Necrotizing Fascitis M72.6 ................................................................10
Neuropathic Joint Disease G62.9 ................................................................11
Osteomielitis Kronis M86.4 ................................................................12
Osteoporosis Z13.820 ................................................................13
Pagets Disease M88 ................................................................14
Pigmented Villonodular Synovitis M12.2 ................................................................15
Pyogenic Infection L98.0 ................................................................16
Sindroma Emboli Lemak T79.1 ................................................................17
Sindroma Kompartemen T79.A ................................................................18
Sindroma Nyeri Kronis G89.4 ................................................................19
Osteoarthritis M15-M19 ................................................................20
Neuropathic Arthritis (Charcots Joint) M12.9 ................................................................21
Gout M10. ................................................................22
Osteochondritis Dissecans M93.2 ................................................................23
Pseudogout M10. ................................................................24

Lower Extremity
Osteomyelitis Kronis M86.3 ................................................................25
Osteoarthritis Hip M16 ................................................................26
Tuberculosis Panggul - ................................................................27
Displasia Acetabulum dan Subluksasi Pinggul Q65.89 ................................................................28

CLINICAL PATHWAY SMF ORTHOPAEDI & TRAUMATOLOGI RSUD Dr. SOETOMO i

 Kode ICD-10 Halaman

Lower Extremity
Dislokasi Pinggul Acquired S73 ................................................................29
Tear of Meniscus M23.3 ................................................................30
Synovial Chondromatosis M71.4 ................................................................31
Synovitis Traumatik Genu M70.5 ................................................................32
Synovitis Nontraumatik Aseptik M65.9 ................................................................33
Arthritis Septik Akut Genu M00.16 ................................................................34
Ruptur Meniscus S83.2 ................................................................35
Ruptur Ligamentum Cruciatum S93.2 ................................................................36
Ruptur Di Bawah Patella M66.86 ................................................................37
Ruptur Di Atas Patella M66.85 ................................................................38
Rheumatic Arthritis Genu M06.9 ................................................................39
Recurrent Dislocation of The Patellar M22.0 ................................................................40
Prepatelar Bursitis (Housemaids Knee) 726.65 ................................................................41
Popliteal Cyst M71.2 ................................................................42
Plica Syndrome M67.52 ................................................................43
Pellegrini-Stieda Disease M71 ................................................................44
Patellofemoral Overload M22.2 ................................................................45
Loose Bodies M23.41 ................................................................46
Kalsifikasi pada Ligamen Medial - ................................................................47
Infrapatellar Bursitis (Clergymans Knee) 726.69 ................................................................48
Haemarthrosis Genu M25.06 ................................................................49
Ankylosing Hip M45 ................................................................50

Musculoskeletal Tumor
Aneurysmal Bone Cyst M85.5 ................................................................51
Chondromyxoid Fibroma D16.- ................................................................52
Chondrosarcoma M9220 ................................................................53
Enchondroma D16.- ................................................................54
Ewing Sarcoma C41.9 ................................................................55
Exostosis (Osteochondroma) D16.- ................................................................56
Fraktur Patologis M84.40 ................................................................57
Giant Cell Tumor C40 ................................................................58
Metastatic Bone Disease C79.5 ................................................................59
Multiple Myeloma C90 ................................................................60
Osteosarcoma C40 ................................................................61
Periosteal Chondroma D16.- ................................................................62
Pigmented Villonodular Synovitis M12.2 ................................................................63

CLINICAL PATHWAY SMF ORTHOPAEDI & TRAUMATOLOGI RSUD Dr. SOETOMO ii

 Kode ICD-10 Halaman

Musculoskeletal Tumor
Simple Bone Cyst M85.4 ................................................................64
Synovial Chondromatosis M71.4 ................................................................65
Synovitis Non-specific M65.9 ................................................................66
Tophus M1A.0X91 ................................................................67

Spine
Acute Intevertebral Disc Prolaps M51.2 ................................................................68
Cervical Spondylosis M47 ................................................................69
Degenerasi dan Prolaps Diskus M48.5 ................................................................70
Fraktur Vertebra Servikal S12 ................................................................71
Fraktur Vertebra Torakolumbal S22.0 ................................................................72
Hernia Nukleus Pulposus M51.24 ................................................................73
Infeksi Spinal Pyogen M46.3 ................................................................74
Infeksi Spinal Tuberculosis M49.0 ................................................................75
Ossification of The Posterior Longitudinal M48.8 ................................................................76
Ligament (OPLL)
Segmental Instability dan Facet Joint M53.2 ................................................................77
Dysfunction
Spinal Stenosis dan Cervical Myelopathy M48.02 ................................................................78
Myelopathy M47.10 ................................................................79
Scoliosis M41 ................................................................80
Spondylitis Tuberculosa A18.01 ................................................................81
Spondylolisthesis M43.1 ................................................................82

Upper Extremity
Adhesive Capsulitis 726.0 ................................................................83
Anterior Instability 840.4 ................................................................84
Avulsi Tendon Bisep Distal S462 ................................................................85
Avulsion of The Distal Tendon of Biceps S.46 ................................................................86
Baseball Pitchers Elbow M79 ................................................................87
Bicipital Tendinitis 726.12 ................................................................88
Bursitis (Olecranon) M70.2 ................................................................89
Carpometacarpal Osteoarthritis M18. ................................................................90
Cedera Pembuluh Darah Tepi T14.5 ................................................................91
Cedera Saraf Tepi T14.4 ................................................................92
Cedera Terbuka pada Tangan & Ekstremitas Atas S61.4 ................................................................93
Tenosynovitis De Quervainss M65.4 ................................................................94
Deformitas Kongenital Tangan S52.1 ................................................................95
Fraktur Barton S52.5 ................................................................96
Fraktur Skapoid S62.0 ................................................................97
Fraktur Styloid Radius (Chauffeurs Fracture) S52.5 ................................................................98
Fraktur Colles S52.5 ................................................................99
Fraktur Antebrachii T10 ................................................................100
Fraktur Galeazzi S52.3 ................................................................101
Fraktur Karpalia S62.1 ................................................................102
Fraktur Lunatum S62.1 ................................................................103
Fraktur Batang Humerus S42.3 ................................................................104
Fraktur Dislokasi Tepi Palmar (Bartons Type S52.5 ................................................................105
Smith)
Fraktur Klavikula S42.0 ................................................................106
Fraktur Kollum Humeri S42.2 ................................................................107

CLINICAL PATHWAY SMF ORTHOPAEDI & TRAUMATOLOGI RSUD Dr. SOETOMO iii
 Kode ICD-10 Halaman

Upper Extremity
Fraktur Monteggia S52.0 ................................................................108
Fraktur Phalang S62.8 ................................................................109
Fraktur Smiths S52.5 ................................................................110
Fraktur Ulna S52.0 ................................................................111
Gout (Elbow) M10.0 ................................................................112
Fraktur Proksimal Humerus S42.2 ................................................................113
Fraktur Skapula S42.1 ................................................................114
Fraktur Suprakondiler Humerus S42.4 ................................................................115
Infeksi Akut pada Tangan 730.04 ................................................................116
Instabilitas Karpalia M25.30 ................................................................117
Jari Picu (Trigger Finger/Tenovanginitis Jari) S52.1 ................................................................118
Kienbocks Disease M87.2 ................................................................119
Kista Ganglion M67.4 ................................................................120
Kontraktur Dupuytren S52.1 ................................................................121
Madelungs Deformity Q74.0 ................................................................122
Osteoarthritis (Elbow) M15.0 ................................................................123
Osteoarthritis Sendi Wrist M18.1 ................................................................124
Posterior Instability 840.4 ................................................................125
Pyogenic Tenosynovitis M65 ................................................................126
Radial Club Hand Q47.0 ................................................................127
Rheumatoid Arthritis Wrist M05.8 ................................................................128
Rotator Cuff Syndrome 726.10 ................................................................129
Ruptur Tendon Biceps 726.62 ................................................................130
Ruptur Tendon Extensor S66.2 ................................................................131
Ruptur Tendon Flexor Upper Extremity S66.0 ................................................................132
Ruptur Tendon Flexor S66.1 ................................................................133
Dislokasi Bahu (anterior) S43.0 ................................................................134
Dislokasi Sterno Clavicula S43.2 ................................................................135
Lesi Plexus Brachialis S14.3 ................................................................136
Stiffness of The Elbow Post Traumatic Stiffness M25.6 ................................................................137
Tennis Elbow (Lateral Epicondylitis) M77.1 ................................................................138
Traumatik Amputasi S48, S58, S68, S78 ................................................................139
Tuberkulosis Sendi Wrist A18.0 ................................................................140
Vulnus Scissum T14.6 ................................................................141

Pediatric Orthopaedi
Amyotropic Lateral Sclerosis S52.1 ................................................................142
Arthrogriposis Multiplex Kongenital Q74.3 ................................................................143
Cerebral Palsy S42.3 ................................................................144
Claw Toes Q66.8 ................................................................145
Congenital Talipes Equinovarus Q66.0 ................................................................146
Duchenne Muscular Dystrophy S37.6 ................................................................147
Fifth Toe Deformities Q66.8 ................................................................148
Flat Foot (Pes Planus) Q66.5 ................................................................149
Frederich Ataxia M34.5 ................................................................150
Hallux Rigidus M20.2 ................................................................151
Hallux Valgus M20.1 ................................................................152
Hammer Toe M20.4 ................................................................153

CLINICAL PATHWAY SMF ORTHOPAEDI & TRAUMATOLOGI RSUD Dr. SOETOMO iv

 Kode ICD-10 Halaman

Pediatric Orthopaedi
Hyperparathyroidism E21.0 ................................................................154
Lesi/Disfungsi Medula Spinal (Karena Tumor, S52.1 ................................................................155
Trauma, Infeksi)
Mallet Toe Q66.8 ................................................................156
Motor Neuron Spinal Muskular Atrofi G12.20 ................................................................157
Osgood-Schlatters Disease M92.5 ................................................................158
Pes Cavus Q66.7 ................................................................159
Poliomielitis Anterior S52.1 ................................................................160
Renal Osteodystrophy N25.0 ................................................................161
Juvenile Rheumatoid Arthritis MO5.8 ................................................................162
Rickets dan Osteomalacia E55.0 ................................................................163
Spina Bifida Q05.9 ................................................................164
Blounts Disease Q68.4 ................................................................165
Perthes Disease Q65.8 ................................................................166
Torticolis M43.6 ................................................................167
Develpmental Displasia of The Hip Q65.8 ................................................................168

CLINICAL PATHWAY SMF ORTHOPAEDI & TRAUMATOLOGI RSUD Dr. SOETOMO v