Type III occipital condyle fracture, unspecified side
ICD-10 S02.112 is a billable code used to indicate a diagnosis of type iii occipital condyle fracture, unspecified side.
A Type III occipital condyle fracture is a specific type of fracture that occurs at the junction of the skull and the spine, affecting the occipital condyles, which are the rounded projections on the underside of the occipital bone. This type of fracture is often associated with significant trauma, such as high-velocity impacts, falls from heights, or motor vehicle accidents. The fracture can lead to instability of the craniovertebral junction, potentially resulting in neurological deficits due to compression of the brainstem or spinal cord. Clinical presentation may include neck pain, occipital headache, and neurological symptoms such as weakness or sensory changes. Diagnosis typically involves imaging studies, including CT scans or MRI, to assess the fracture's extent and any associated injuries. Management may require surgical intervention, particularly if there is instability or neurological compromise, followed by rehabilitation to restore function and mobility.
Documentation must include details of the mechanism of injury, initial assessment findings, and any imaging performed.
Trauma patients presenting with head and neck injuries after falls or vehicular accidents.
Ensure that all neurological assessments are documented to support the diagnosis and any potential complications.
Operative reports must detail the surgical approach, findings, and any fixation methods used.
Patients requiring surgical stabilization of the craniovertebral junction due to fracture instability.
Document any intraoperative findings that may affect coding, such as additional injuries or complications.
Used in cases where surgical intervention is required for stabilization of the occipital condyle fracture.
Operative report detailing the procedure and any findings.
Ensure that the surgical approach and any complications are documented.
Specifying the side is crucial for accurate coding and treatment planning, as it can affect the management approach and potential complications.
