Posterior displaced Type II dens fracture
ICD-10 S12.111 is a billable code used to indicate a diagnosis of posterior displaced type ii dens fracture.
A posterior displaced Type II dens fracture refers to a specific type of fracture involving the odontoid process (dens) of the second cervical vertebra (C2). This injury typically occurs due to high-energy trauma, such as motor vehicle accidents or falls, where the head is forcefully flexed or extended. The dens is crucial for the rotation of the head and neck, and a fracture in this area can lead to instability and potential spinal cord injury. The Type II classification indicates that the fracture occurs at the base of the dens, which is the most common type of dens fracture and is associated with a higher risk of nonunion. Clinical presentation may include neck pain, limited range of motion, and neurological deficits if the spinal cord is compromised. Diagnosis is primarily through imaging studies, including X-rays and CT scans, which help assess the fracture's displacement and alignment. 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 complications such as nonunion or neurological impairment.
Emergency department notes must include a detailed account of the mechanism of injury, initial assessment findings, and imaging results.
Patients presenting with neck pain after trauma, requiring imaging and potential stabilization.
Ensure that all relevant imaging studies are documented and that any neurological assessments are clearly noted.
Operative reports must detail the surgical approach, findings, and any fixation methods used.
Surgical intervention for unstable dens fractures requiring stabilization.
Document the rationale for surgical intervention and any intraoperative findings that may affect coding.
Used in cases requiring surgical stabilization of a dens fracture.
Operative report must detail the surgical approach and fixation method.
Ensure that the surgical indication aligns with the diagnosis of a posterior displaced Type II dens fracture.
A Type II dens fracture is significant due to its association with a higher risk of nonunion and potential neurological complications, making accurate diagnosis and management critical.
