M71.012 Abscess of bursa, left shoulder

Name of the Condition

• Abscess of bursa, left shoulder

Summary

An abscess of the bursa, left shoulder, is a localized collection of pus within the bursa of the left shoulder, resulting from infection or inflammation. This condition causes pain, swelling, and functional impairment at the affected site. Bursae are small fluid-filled sacs that reduce friction between tissues, and when infected, they can become inflamed and filled with purulent material.

Causes

Abscesses of the bursa typically result from bacterial infection, often introduced through direct trauma, skin breakdown, or spread from adjacent tissues. Staphylococcus aureus is a common causative organism. Non-infectious causes, such as chronic inflammation or foreign body reaction, may also lead to bursal abscess formation.

Risk Factors

• Recent injury or surgery near the left shoulder bursa
• Skin infections or open wounds in the vicinity
• Immunocompromised states (e.g., diabetes, HIV)
• Chronic inflammatory conditions (e.g., rheumatoid arthritis)
• Repetitive motion or pressure on the left shoulder

Symptoms

• Localized pain, swelling, and warmth over the left shoulder bursa
• Redness or erythema at the site
• Fever or systemic signs of infection
• Limited range of motion in the left shoulder
• Pus drainage if the abscess ruptures

Diagnosis

Diagnosis involves a physical examination to assess bursal characteristics, including tenderness, fluctuance, and warmth. Imaging (e.g., ultrasound) may confirm fluid collection. Aspiration of the bursa may be performed to identify the causative organism and guide treatment.

Treatment Options

Treatment typically includes antibiotic therapy to address the underlying infection. In some cases, surgical drainage of the abscess may be necessary to remove pus and promote healing. Pain management and rest of the affected shoulder are also recommended.

Prognosis and Follow-Up

With appropriate treatment, most bursal abscesses resolve without long-term complications. Follow-up care may involve monitoring for recurrence or signs of spreading infection. Physical therapy may be recommended to restore shoulder function once the infection is controlled.

Complications

Untreated or inadequately treated abscesses can lead to the spread of infection to surrounding tissues or bloodstream. Chronic bursal inflammation or persistent pain may occur in some cases.

Lifestyle & Prevention

Avoiding trauma to the left shoulder, maintaining good skin hygiene, and managing chronic inflammatory conditions can reduce the risk of bursal abscess formation. Prompt treatment of minor skin infections near the shoulder is also advisable.

When to Seek Professional Help

Seek medical attention if you experience persistent shoulder pain, swelling, redness, or fever, as these may indicate an abscess or spreading infection. Immediate care is needed if pus drainage or worsening symptoms occur.

Tips for Medical Coders

This code (M71.012) is specific to an abscess of the bursa in the left shoulder. Documentation should clearly specify the location (left shoulder) and confirm the presence of a bursal abscess. Ensure the medical record supports the diagnosis with clinical findings or imaging results.