Sternomastoid injury due to birth injury
ICD-10 P15.2 is a billable code used to indicate a diagnosis of sternomastoid injury due to birth injury.
Sternomastoid injury due to birth injury refers to damage to the sternocleidomastoid muscle, typically resulting from mechanical forces during delivery. This injury can lead to a condition known as torticollis, where the infant's head tilts to one side due to muscle tightness. The injury may occur during difficult deliveries, particularly in cases involving shoulder dystocia or excessive lateral traction on the head. Clinical manifestations may include a noticeable head tilt, limited range of motion in the neck, and potential asymmetry in the face. Diagnosis is primarily clinical, supported by physical examination findings. Treatment often involves physical therapy to improve neck mobility and muscle strength. In some cases, surgical intervention may be necessary if conservative measures fail. Understanding this condition is crucial for neonatologists and pediatricians, as early identification and management can significantly improve outcomes for affected infants.
Detailed physical examination findings, including range of motion and muscle tone assessments.
Infants presenting with head tilt and limited neck mobility in the NICU.
Consideration of other birth injuries and their potential impact on treatment and outcomes.
Comprehensive history and physical examination, including developmental milestones.
Pediatric follow-up visits for infants with a history of sternomastoid injury.
Monitoring for long-term effects on development and physical therapy needs.
Used for infants undergoing physical therapy for neck mobility.
Document the specific exercises and progress notes.
Neonatologists should coordinate with physical therapists for comprehensive care.
Treatment typically involves physical therapy to improve neck mobility and muscle strength. In some cases, surgical intervention may be necessary if conservative measures do not yield improvement.
