Nondisplaced Type II dens fracture
ICD-10 S12.112 is a billable code used to indicate a diagnosis of nondisplaced type ii dens fracture.
A nondisplaced 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 trauma, such as a fall or motor vehicle accident, where the neck is subjected to excessive force. The dens is crucial for the rotation of the head and neck, and a fracture in this area can lead to instability and potential neurological complications. In a Type II fracture, the fracture line is located at the base of the dens, and the fracture is classified as nondisplaced when the fragments remain in their anatomical position. Diagnosis is usually confirmed through imaging studies, such as X-rays or CT scans, which can visualize the fracture and assess for any associated injuries. Management may involve conservative treatment with immobilization or surgical intervention, depending on the stability of the fracture and the patient's overall condition. Complications can include nonunion, malunion, or neurological deficits if the spinal cord is compromised. Accurate coding is essential for proper reimbursement and tracking of patient outcomes.
Documentation must include details of the mechanism of injury, initial assessment findings, imaging results, and any immediate interventions performed.
Patients presenting with neck pain after trauma, with or without neurological symptoms.
Ensure that all imaging studies are clearly documented and correlate with the diagnosis.
Operative reports must detail the surgical approach, findings, and any fixation methods used for stabilization.
Surgical management of unstable Type II dens fractures requiring fixation.
Document any intraoperative findings that may affect coding, such as additional injuries or complications.
Used in surgical management of unstable dens fractures.
Operative report detailing the procedure and indications for surgery.
Ensure that the surgical approach and any complications are documented.
Type I fractures occur at the tip of the dens and are typically stable, while Type II fractures occur at the base and can be unstable, requiring careful management.
