Puncture wound with foreign body of shoulder
ICD-10 S41.04 is a billable code used to indicate a diagnosis of puncture wound with foreign body of shoulder.
A puncture wound with a foreign body of the shoulder typically occurs when an object penetrates the skin and underlying tissues, potentially leading to complications such as infection, inflammation, or damage to surrounding structures. This type of injury can arise from various incidents, including accidents involving sharp objects, falls, or sports injuries. Clinically, the presence of a foreign body may complicate the healing process and necessitate surgical intervention for removal. The shoulder region is particularly susceptible to such injuries due to its anatomical complexity, which includes the humerus, scapula, and clavicle, as well as the rotator cuff muscles and tendons. In cases where the puncture wound is associated with dislocations or fractures, such as a humeral fracture or rotator cuff injury, the treatment plan may involve orthopedic surgical repairs. Proper assessment and documentation of the injury's extent, the foreign body type, and any associated injuries are crucial for accurate coding and management.
Detailed operative notes, imaging studies, and post-operative care plans.
Surgical removal of foreign bodies, repair of associated fractures, and management of dislocations.
Ensure that all associated injuries are documented to support the complexity of the case.
Initial assessment notes, imaging results, and treatment provided in the emergency setting.
Initial evaluation of puncture wounds, foreign body identification, and stabilization of the patient.
Accurate documentation of the mechanism of injury and immediate interventions is critical.
Used when aspiration of the shoulder joint is necessary due to fluid accumulation after a puncture wound.
Document the reason for aspiration and the findings during the procedure.
Orthopedic specialists should ensure that the procedure is justified based on clinical findings.
Documentation should include the mechanism of injury, type of foreign body, location, any associated injuries, and the treatment provided.
