2-part nondisplaced fracture of surgical neck of unspecified humerus
ICD-10 S42.226 is a billable code used to indicate a diagnosis of 2-part nondisplaced fracture of surgical neck of unspecified humerus.
A 2-part nondisplaced fracture of the surgical neck of the humerus typically occurs in the proximal region of the arm, just below the head of the humerus. This type of fracture is characterized by the absence of displacement, meaning the bone fragments remain in their normal anatomical position. Such fractures are often the result of low-energy trauma, such as falls, particularly in older adults with osteoporotic bones. Clinical presentation may include localized pain, swelling, and limited range of motion in the shoulder. Diagnosis is confirmed through imaging studies, primarily X-rays, which reveal the fracture line without displacement. Treatment usually involves conservative management, including immobilization with a sling and physical therapy to restore function. Surgical intervention may be considered if there are complications or if conservative treatment fails. Understanding the nuances of this fracture type is crucial for appropriate coding and management.
Detailed imaging reports, surgical notes if applicable, and follow-up care documentation.
Fractures resulting from falls, sports injuries, or accidents requiring surgical intervention.
Ensure clear documentation of fracture characteristics and treatment plans to support coding.
Initial evaluation notes, progress reports, and discharge summaries detailing rehabilitation outcomes.
Patients undergoing rehabilitation post-fracture for range of motion and strength recovery.
Document specific functional limitations and progress to justify therapy services.
Used when a rotator cuff injury is present alongside the fracture.
Operative reports detailing the procedure and findings.
Orthopedic surgeons should ensure accurate coding for both the fracture and any concurrent procedures.
A displaced fracture involves a break in the bone where the ends are not aligned, while a nondisplaced fracture means the bone cracks but maintains its normal position.
