Unspecified nondisplaced fracture of surgical neck of unspecified humerus
ICD-10 S42.216 is a billable code used to indicate a diagnosis of unspecified nondisplaced fracture of surgical neck of unspecified humerus.
The surgical neck of the humerus is a common site for fractures, particularly in older adults and those with osteoporosis. An unspecified nondisplaced fracture at this location indicates that the bone has cracked but has not moved out of its normal alignment. This type of fracture can occur due to falls, direct trauma, or repetitive stress. Symptoms typically include pain, swelling, and limited range of motion in the shoulder. Diagnosis is often confirmed through imaging studies such as X-rays or MRI. Treatment may involve conservative management with rest, ice, and immobilization, or surgical intervention if the fracture is associated with significant instability or if there are complications. Rehabilitation is crucial for restoring function and strength in the shoulder joint. Understanding the nuances of this fracture type is essential for accurate coding and appropriate management.
Detailed operative notes, imaging results, and follow-up care plans.
Fractures resulting from falls, sports injuries, or osteoporotic events.
Ensure clarity in documentation regarding the fracture's displacement status and any associated injuries.
Progress notes detailing rehabilitation goals, treatment modalities, and patient response.
Post-fracture rehabilitation focusing on restoring range of motion and strength.
Document functional limitations and progress towards rehabilitation goals.
Used in conjunction with S42.216 if a rotator cuff injury is also present.
Operative report detailing the procedure and findings.
Orthopedic surgeons should document any associated injuries to ensure accurate coding.
A displaced fracture means the bone fragments have moved out of alignment, while a nondisplaced fracture indicates the bone remains in its normal position despite being cracked.
