Fracture of orbital floor
ICD-10 S02.3 is a billable code used to indicate a diagnosis of fracture of orbital floor.
A fracture of the orbital floor, also known as a blowout fracture, occurs when there is a break in the bony structure of the orbital floor, typically due to blunt trauma to the face. This type of fracture can result from various mechanisms, including sports injuries, falls, physical altercations, or motor vehicle accidents. Clinically, patients may present with symptoms such as diplopia (double vision), enophthalmos (sunken eye), and periorbital edema. The fracture can lead to entrapment of the extraocular muscles, which may require surgical intervention. Diagnosis is primarily made through clinical examination and imaging studies, such as CT scans, which provide detailed visualization of the fracture and any associated injuries. Management may involve observation for minor fractures or surgical repair for more significant injuries, especially if there is muscle entrapment or significant cosmetic deformity. Complications can include persistent diplopia, vision loss, and chronic pain if not appropriately managed.
Documentation must include a detailed account of the mechanism of injury, clinical findings, and any imaging results.
Patients presenting with facial trauma after a fall or sports injury.
Ensure that all relevant symptoms and physical exam findings are documented to support the diagnosis.
Operative reports must detail the surgical approach, findings, and any repairs made to the orbital floor.
Surgical repair of an orbital floor fracture due to trauma.
Document any complications encountered during surgery and post-operative care.
Used when surgical intervention is performed to repair the fracture.
Operative report detailing the procedure and findings.
Ensure that the surgical approach and any complications are documented.
Common causes include blunt trauma from sports injuries, falls, physical altercations, and motor vehicle accidents.
Diagnosis is typically made through a combination of clinical examination and imaging studies, particularly CT scans, which can reveal the extent of the fracture and any associated injuries.
