S42.112 Displaced fracture of body of scapula, left shoulder

Name of the Condition

• Displaced fracture of body of scapula, left shoulder

Summary

A displaced fracture of the body of the scapula involves a break in the main, flat portion of the shoulder blade bone, with the fractured fragments shifted out of their normal alignment. This condition affects the left shoulder and may result from significant trauma, leading to pain, functional impairment, and potential complications if not properly managed.

Causes

Traumatic injury is the primary cause, often resulting from high-impact events such as motor vehicle accidents, falls from height, or direct forceful blows to the shoulder. Sports-related collisions or crush injuries may also lead to this type of fracture.

Risk Factors

• Participation in contact sports or activities with a high risk of falls.
• Osteoporosis or other bone-weakening conditions.
• Advanced age, which may increase susceptibility to fractures from minor trauma.
• Previous shoulder or upper arm injuries that affect bone integrity.

Symptoms

• Intense pain in the shoulder or upper back, worsening with movement.
• Swelling, bruising, or tenderness over the shoulder blade.
• Limited range of motion in the shoulder joint.
• Difficulty lifting or rotating the arm.
• Possible visible deformity or instability in severe cases.

Diagnosis

Diagnosis begins with a physical examination to assess pain, swelling, and range of motion. Imaging studies, typically X-rays, are used to confirm the fracture and evaluate displacement. In some cases, CT scans may be ordered to provide detailed visualization of the fracture pattern and surrounding structures.

Treatment Options

Treatment depends on the severity of the fracture and displacement. Non-displaced or minimally displaced fractures may be managed with immobilization using a sling, pain relief, and physical therapy. Displaced fractures often require surgical intervention to realign and stabilize the bone, followed by rehabilitation to restore function.

Prognosis and Follow-Up

Most patients recover well with appropriate treatment, though recovery time varies based on fracture severity and treatment approach. Follow-up appointments are necessary to monitor healing, assess range of motion, and adjust rehabilitation plans. Full recovery may take several months, with ongoing therapy to restore strength and mobility.

Complications

Potential complications include nonunion or malunion of the fracture, chronic pain, shoulder stiffness, nerve or blood vessel damage, or post-traumatic arthritis. Infection or hardware-related issues may occur in surgically treated cases.

Lifestyle & Prevention

Avoid high-risk activities or use protective gear during sports. Maintain bone health through a balanced diet rich in calcium and vitamin D, and engage in regular weight-bearing exercise. Fall prevention strategies, such as home modifications, are important for older adults.

When to Seek Professional Help

Seek immediate medical attention for severe pain, visible deformity, inability to move the arm, or signs of infection (e.g., fever, redness, drainage). Persistent pain or limited mobility after initial treatment also warrants evaluation.

Tips for Medical Coders

Document the laterality (left shoulder) and displacement status clearly. Ensure the fracture is specified as involving the body of the scapula, not other parts like the glenoid or acromion. For surgical cases, note the type of procedure and any hardware used. Follow clinical documentation guidelines to support code assignment.