Type II occipital condyle fracture, unspecified side
ICD-10 S02.111 is a billable code used to indicate a diagnosis of type ii occipital condyle fracture, unspecified side.
A Type II occipital condyle fracture is characterized by a fracture of the occipital condyle, which is the rounded end of the occipital bone that articulates with the first cervical vertebra (atlas). This type of fracture is typically classified as a non-displaced fracture, meaning that the bone fragments remain in alignment. Occipital condyle fractures can occur due to high-energy trauma, such as motor vehicle accidents, falls from significant heights, or sports injuries. Symptoms may include neck pain, occipital headache, and neurological deficits if there is associated injury to the spinal cord or cranial nerves. Diagnosis is primarily through imaging studies, such as CT scans or MRI, which can reveal the fracture and assess for any potential complications. Management often involves conservative treatment, including immobilization and pain management, although surgical intervention may be necessary in cases of instability or neurological compromise. Complications can include chronic pain, neurological deficits, and instability of the cervical spine.
Comprehensive documentation of the patient's presentation, mechanism of injury, and initial imaging results.
Patients presenting with neck pain after trauma, requiring imaging to rule out fractures.
Ensure that the mechanism of injury is clearly documented to support the diagnosis.
Detailed operative notes, including indications for surgery, surgical findings, and post-operative care.
Surgical intervention for unstable fractures or those with neurological compromise.
Document any intraoperative findings that may affect coding, such as additional injuries.
Used in cases where there is neurological compromise due to the fracture.
Operative report detailing the need for decompression and findings during surgery.
Neurosurgery documentation must include pre-operative assessments and post-operative outcomes.
Specifying the side is crucial for accurate coding and treatment planning, as it can affect the management and potential complications associated with the fracture.
