Open wound of shoulder and upper arm
Chapter 19:Injury, poisoning and other consequences of external causes
ICD-10 S41 is a billable code used to indicate a diagnosis of open wound of shoulder and upper arm.
An open wound of the shoulder and upper arm refers to a break in the skin and underlying tissues in the area surrounding the shoulder joint and upper arm. This type of injury can result from various causes, including trauma, falls, or accidents. Open wounds can be classified into different types, such as lacerations, abrasions, and punctures, and may involve damage to muscles, tendons, nerves, and blood vessels. In the context of shoulder dislocations, the open wound may occur due to the forceful impact that causes the dislocation, leading to skin breaches. Humeral fractures, particularly those involving the surgical neck or shaft, can also present as open wounds if the fracture fragments penetrate the skin. Rotator cuff injuries may accompany open wounds, especially in cases of severe trauma. Orthopedic surgical repairs, such as debridement or fixation of fractures, may be necessary to treat these injuries effectively. Proper management of open wounds is crucial to prevent complications such as infection, delayed healing, and functional impairment of the shoulder and upper arm.
Detailed operative reports, including descriptions of the wound, associated injuries, and surgical techniques used.
Open fractures requiring surgical fixation, traumatic shoulder dislocations with associated skin breaches.
Ensure accurate coding of both the open wound and any surgical procedures performed.
Comprehensive notes on the mechanism of injury, initial assessment findings, and treatment provided.
Patients presenting with traumatic shoulder injuries, including open wounds from falls or accidents.
Document the extent of the wound and any immediate interventions performed.
Used when a rotator cuff injury is repaired surgically following an open wound.
Operative report detailing the extent of the injury and repair technique.
Orthopedic surgeons must document the specifics of the rotator cuff repair.
An open wound involves a break in the skin, exposing underlying tissues, while a closed wound does not penetrate the skin and typically involves bruising or swelling.
