Name of the Condition

• Fracture of unspecified part of scapula, right shoulder, subsequent encounter for fracture with routine healing
• ICD-10 Code: S42.101D

Summary

A fracture of the scapula refers to a break in the shoulder blade bone. This specific condition pertains to a right shoulder scapula fracture that is undergoing routine healing following initial treatment.

Causes

• Traumatic injury, such as a fall, car accident, or sports injury.
• Direct impact to the shoulder area.

Risk Factors

• Participation in contact sports or high-impact activities.
• Osteoporosis or other conditions that weaken bones.
• Advanced age, leading to increased likelihood of falls and brittle bones.

Symptoms

• Pain in the shoulder area, especially when moving the arm.
• Swelling or bruising over the shoulder blade.
• Limited range of motion in the shoulder joint.

Diagnosis

• Physical examination to assess pain and movement.
• Imaging tests, such as X-rays, CT scans, or MRIs, to confirm the fracture and its exact location.

Treatment Options

• Immobilization of the shoulder with a sling or brace to allow healing.
• Pain management with medications such as NSAIDs.
• Physical therapy to restore movement and strength once healing progresses.

Prognosis and Follow-Up

• With appropriate treatment, the outlook is generally good, with most fractures healing well.
• Regular follow-up appointments are necessary to ensure proper alignment and healing progress.

Complications

• Improper healing or malunion of the fracture.
• Shoulder stiffness or reduced range of motion.
• Nerve or blood vessel damage around the shoulder area.

Lifestyle & Prevention

• Engaging in exercises to strengthen shoulder and back muscles can help prevent injuries.
• Taking precautions, such as using protective gear when participating in high-risk activities.

When to Seek Professional Help

• Severe pain or swelling in the shoulder after an injury.
• Numbness, tingling, or weakness in the arm or hand.
• Difficulty or inability to move the shoulder or arm.

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS) - orthoinfo.aaos.org
• National Institute of Arthritis and Musculoskeletal and Skin Diseases - niams.nih.gov

Tips for Medical Coders

• Ensure the correct laterality is documented (right shoulder in this case).
• Verify that this is a subsequent encounter and not the initial episode, using the 'D' for routine healing.
• Avoid misclassifying under unspecified codes if further details are available in the patient's records.