Unspecified occipital condyle fracture
ICD-10 S02.113 is a billable code used to indicate a diagnosis of unspecified occipital condyle fracture.
An occipital condyle fracture refers to a break in the bony structures at the base of the skull, specifically at the occipital condyles, which articulate with the first cervical vertebra (atlas). This type of fracture is often associated with high-energy trauma, such as motor vehicle accidents, falls from significant heights, or violent sports injuries. The clinical presentation may include neck pain, occipital headache, and neurological deficits due to potential involvement of the spinal cord or cranial nerves. Diagnosis typically involves imaging studies, such as CT scans or MRI, to confirm the fracture and assess for any associated injuries. Management may vary from conservative treatment, including immobilization and pain management, to surgical intervention in cases of instability or neurological compromise. Complications can include chronic pain, neurological deficits, or instability of the cervical spine, necessitating careful monitoring and follow-up.
Complete documentation of initial assessment, mechanism of injury, and neurological examination findings.
Patients presenting with trauma from falls or vehicular accidents, requiring immediate imaging and evaluation.
Ensure thorough documentation of any neurological deficits and imaging results to support coding.
Detailed operative notes, including indications for surgery, findings, and postoperative care.
Surgical intervention for unstable fractures or decompression of neural structures.
Document all surgical approaches and any complications encountered during the procedure.
Performed for decompression of the spinal cord due to occipital condyle fracture.
Operative report detailing the procedure and indications.
Ensure that the surgical necessity is well-documented to support the procedure.
Common causes include high-energy trauma such as motor vehicle accidents, falls from heights, and sports injuries.
Diagnosis is typically made through imaging studies like CT or MRI, which reveal the fracture and assess for any associated injuries.
Treatment may range from conservative management with immobilization and pain control to surgical intervention for unstable fractures.
