S42.112A Displaced fracture of body of scapula, left shoulder, initial encounter for closed fracture

Name of the Condition

• Displaced fracture of body of scapula, left shoulder, initial encounter for closed fracture

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 is classified as a closed fracture, meaning the skin remains intact. The scapula is a triangular bone that connects the upper arm to the collarbone and trunk, and fractures in its body can impact shoulder function.

Causes

Traumatic injury is the primary cause of scapular fractures. Common mechanisms include falls, motor vehicle accidents, sports-related impacts, or direct blows to the shoulder area. High-energy trauma, such as that from a collision, often results in displaced fractures due to the force required to shift bone fragments.

Risk Factors

• Participation in contact sports or high-impact activities.
• Osteoporosis or other bone-weakening conditions.
• Advanced age, which may increase susceptibility to falls.
• Previous shoulder or upper arm injuries that affect bone integrity.

Symptoms

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

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. CT scans may be ordered for complex cases to assess bone alignment and rule out associated injuries. The classification as a closed fracture is confirmed by the absence of skin penetration.

Treatment Options

Treatment depends on fracture severity and displacement. Non-displaced or minimally displaced fractures may be managed with immobilization, such as a sling, and pain relief. Displaced fractures often require surgical intervention to realign and stabilize the bone using plates, screws, or pins. Physical therapy is typically recommended during recovery to restore strength and mobility.

Prognosis and Follow-Up

Most patients recover well with appropriate treatment, though recovery time varies based on fracture severity and treatment. Follow-up appointments monitor healing through imaging and assess functional recovery. Physical therapy may be needed to regain full shoulder function. Long-term outcomes are generally favorable with proper management.

Complications

Potential complications include nonunion or malunion of the fracture, persistent pain, or limited shoulder mobility. Nerve or blood vessel injury near the scapula is rare but possible. Infection risk is low for closed fractures but may increase with surgical intervention.

Lifestyle & Prevention

Avoid high-impact activities until cleared by a healthcare provider. Strengthen shoulder and upper back muscles to support the scapula. Use protective gear during contact sports. Maintain bone health through adequate calcium and vitamin D intake, especially for those with osteoporosis.

When to Seek Professional Help

Seek immediate care for severe pain, visible deformity, or inability to move the arm. Contact a healthcare provider if pain worsens, swelling increases, or new symptoms like numbness or tingling develop. Follow up as scheduled to ensure proper healing.

Tips for Medical Coders

Document the fracture as displaced, specify the left shoulder, and confirm it is an initial encounter for a closed fracture. Ensure clinical notes support the displacement and absence of skin penetration. Use this code for the first encounter of a closed, displaced scapular body fracture on the left side.