Fracture of medial orbital wall, unspecified side
ICD-10 S02.839 is a billable code used to indicate a diagnosis of fracture of medial orbital wall, unspecified side.
A fracture of the medial orbital wall is a type of facial fracture that occurs in the bony structure surrounding the eye. This injury can result from various mechanisms, including blunt trauma, falls, or sports injuries. The medial orbital wall is particularly susceptible to fractures due to its thin structure and proximity to the nasal cavity. Symptoms may include pain, swelling, bruising around the eyes (periorbital ecchymosis), diplopia (double vision), and potential vision changes. Diagnosis typically involves a thorough clinical examination and imaging studies, such as CT scans, to assess the extent of the fracture and any associated injuries to the surrounding structures. Management may involve conservative treatment with pain control and observation for minor fractures, while more severe cases may require surgical intervention to repair the fracture and restore orbital integrity. Complications can include persistent diplopia, enophthalmos (sunken eye), and potential vision loss if not properly managed.
Documentation should include a detailed account of the mechanism of injury, clinical findings, and any imaging results.
Patients presenting with facial trauma from falls, assaults, or sports injuries.
Ensure that all relevant injuries are documented to avoid undercoding or misclassification.
Operative reports must detail the surgical approach, findings, and any repairs performed.
Surgical intervention for significant fractures requiring reconstruction.
Document any complications or additional procedures performed during surgery.
Used when surgical repair is performed for a medial orbital wall fracture.
Operative report must detail the procedure and findings.
Ensure that the surgical approach is clearly documented.
Common causes include blunt trauma from falls, sports injuries, and assaults. The thin nature of the medial wall makes it particularly vulnerable.
