Posterior displaced fracture of sternal end of unspecified clavicle
ICD-10 S42.016 is a billable code used to indicate a diagnosis of posterior displaced fracture of sternal end of unspecified clavicle.
A posterior displaced fracture of the sternal end of the clavicle typically occurs due to high-energy trauma, such as a fall or a direct blow to the shoulder. This type of fracture can lead to significant complications, including injury to surrounding structures such as the brachial plexus and subclavian vessels. Clinically, patients may present with shoulder pain, swelling, and limited range of motion. Physical examination often reveals tenderness over the sternal end of the clavicle, and imaging studies, particularly X-rays, are essential for diagnosis. Treatment may vary from conservative management, including immobilization and physical therapy, to surgical intervention, especially in cases of significant displacement or associated injuries. Surgical options may include open reduction and internal fixation (ORIF) to restore anatomical alignment and stability. The prognosis is generally favorable with appropriate treatment, although complications such as nonunion or malunion can occur.
Detailed operative notes, imaging reports, and follow-up assessments are essential.
Fractures resulting from sports injuries, falls, or vehicular accidents.
Documentation must clearly indicate the type of fracture and any surgical interventions performed.
Comprehensive assessments of functional limitations and rehabilitation plans.
Patients undergoing rehabilitation post-fracture repair.
Focus on recovery goals and progress notes to support ongoing treatment.
Used when surgical intervention is performed for a displaced fracture.
Operative report detailing the procedure and findings.
Orthopedic surgeons must document the surgical approach and fixation method.
Posterior displacement can lead to complications such as vascular or nerve injury, making it critical to assess and document accurately for treatment planning.
