Type II dens fracture
ICD-10 S12.11 is a billable code used to indicate a diagnosis of type ii dens fracture.
A Type II dens fracture, also known as an odontoid fracture, occurs at the second cervical vertebra (C2), specifically at the dens, which is a bony projection that extends upward from the body of the vertebra. This type of fracture is characterized by a fracture through the base of the dens, which can lead to instability of the cervical spine and potential neurological compromise. Mechanisms of injury typically include high-energy trauma such as motor vehicle accidents, falls from heights, or sports-related injuries. Clinical presentation may include neck pain, restricted range of motion, and neurological symptoms if the spinal cord is affected. Diagnosis is primarily through imaging studies, including X-rays and MRI, to assess the fracture's location and any associated spinal cord injury. Management often involves immobilization with a cervical collar or halo vest, and in some cases, surgical intervention may be necessary to stabilize the fracture and prevent further complications. Complications can include nonunion of the fracture, neurological deficits, and chronic pain.
Documentation must include a thorough assessment of the patient's neurological status, mechanism of injury, and imaging results.
Patients presenting with acute neck pain after trauma, requiring immediate imaging and evaluation.
Ensure that all relevant imaging studies are documented and that the mechanism of injury is clearly described.
Operative reports must detail the surgical approach, fixation methods, and any intraoperative findings.
Surgical intervention for unstable Type II dens fractures requiring stabilization.
Document the rationale for surgical intervention and any pre-existing conditions that may affect healing.
Used for surgical stabilization of a Type II dens fracture.
Operative report must detail the surgical approach and fixation method.
Ensure that the surgical indication aligns with the diagnosis.
The primary mechanism of injury for a Type II dens fracture is typically high-energy trauma, such as motor vehicle accidents or falls from significant heights.
