Fracture of orbital floor, right side
ICD-10 S02.31 is a billable code used to indicate a diagnosis of fracture of orbital floor, right side.
A fracture of the orbital floor, also known as a blowout fracture, occurs when there is a break in the bony structure of the orbital floor, typically due to blunt trauma. This injury often results from incidents such as falls, sports injuries, or physical altercations. The right side designation indicates that the fracture is localized to the right orbital floor. Clinically, patients may present with symptoms such as diplopia (double vision), enophthalmos (sunken eye), and periorbital edema. The mechanism of injury usually involves a sudden increase in intraorbital pressure, causing the thin bone of the orbital floor to fracture. Diagnosis is primarily through clinical examination and imaging studies, such as CT scans, which provide detailed visualization of the fracture and any associated injuries to the surrounding structures. Management may involve observation for minor fractures or surgical intervention for more severe cases, particularly if there is significant displacement or involvement of the ocular structures. Complications can include persistent diplopia, vision loss, and chronic pain if not properly addressed.
Documentation must include details of the mechanism of injury, clinical findings, and any imaging results.
Patients presenting with facial trauma after a fall or sports injury.
Ensure that all relevant symptoms and signs are documented to support the diagnosis.
Operative reports should detail the surgical approach, findings, and any repairs made to the orbital floor.
Surgical intervention for significant fractures with displacement or associated ocular injuries.
Document any pre-existing conditions that may affect surgical outcomes.
Used when surgical intervention is required for a fracture repair.
Operative report detailing the procedure performed and findings.
Ensure that the surgical approach and any complications are documented.
A CT scan of the facial bones is typically required to confirm the presence and extent of an orbital floor fracture.
