Fracture of base of skull
ICD-10 S02.1 is a billable code used to indicate a diagnosis of fracture of base of skull.
A fracture of the base of the skull is a serious injury that occurs at the bottom of the skull, where the skull meets the spine. This type of fracture can result from high-impact trauma, such as motor vehicle accidents, falls from significant heights, or violent assaults. Clinical manifestations may include neurological deficits, cerebrospinal fluid (CSF) leaks, and signs of increased intracranial pressure. Patients may present with symptoms such as headache, confusion, loss of consciousness, or focal neurological signs. Diagnosis typically involves imaging studies, including CT scans or MRI, to assess the extent of the fracture and any associated brain injury. Management may require surgical intervention, especially if there is significant displacement of bone fragments or if there is a risk of brain injury. Close monitoring for complications such as infection, hematoma formation, or neurological deterioration is essential. Given the potential for serious outcomes, timely and accurate diagnosis and treatment are critical.
Documentation must include a thorough assessment of the patient's neurological status, mechanism of injury, and any immediate interventions performed.
Patients presenting after a fall or motor vehicle accident with altered mental status.
Emergency physicians should ensure that all imaging results and consultations are documented to support the diagnosis.
Operative reports must detail the surgical approach, findings, and any complications encountered during the procedure.
Surgical intervention for decompression or repair of skull base fractures.
Surgeons should document the rationale for surgical intervention and any postoperative care provided.
Used when a patient with a skull base fracture develops an abscess.
Document the indication for drainage and the findings during the procedure.
Neurosurgeons should ensure that all relevant imaging and clinical findings are included.
Common causes include high-impact trauma such as motor vehicle accidents, falls from heights, and blunt force trauma.
Skull base fractures typically present with specific neurological symptoms and require imaging to confirm the location and extent of the injury.
