Fracture of orbital roof
ICD-10 S02.12 is a billable code used to indicate a diagnosis of fracture of orbital roof.
A fracture of the orbital roof refers to a break in the bony structure that forms the upper boundary of the eye socket. This type of fracture is often associated with significant trauma, such as from motor vehicle accidents, falls, or sports injuries. The orbital roof is a critical area as it houses important structures, including the optic nerve and various ocular muscles. Symptoms may include periorbital swelling, bruising, diplopia (double vision), and in severe cases, vision loss. Diagnosis typically involves a thorough clinical examination and imaging studies, such as CT scans, to assess the extent of the fracture and any associated injuries. Management may range from conservative treatment, such as observation and pain management, to surgical intervention to repair the fracture and restore orbital integrity. Complications can include persistent diplopia, enophthalmos (sunken eye), and potential damage to the optic nerve, necessitating careful monitoring and follow-up.
Documentation must include details of the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting with facial trauma after a fall or accident, often requiring immediate imaging.
Ensure that all symptoms, including visual disturbances, are documented to support the diagnosis.
Operative reports must detail the surgical approach, findings, and any repairs made to the orbital roof.
Surgical repair of the orbital roof following trauma, often involving reconstruction techniques.
Document any complications encountered during surgery and the rationale for surgical intervention.
Used when surgical intervention is performed to repair the fracture.
Operative report detailing the procedure, findings, and any complications.
Ensure that the surgical approach is clearly documented to support the coding.
Common causes include blunt trauma from falls, motor vehicle accidents, sports injuries, and physical altercations.
Diagnosis is typically made through a combination of clinical examination and imaging studies, particularly CT scans, which can reveal the extent of the fracture and any associated injuries.
Complications can include persistent double vision, enophthalmos, and damage to the optic nerve, which may require surgical intervention.
