S42.115 Nondisplaced fracture of body of scapula, left shoulder

Name of the Condition

• Nondisplaced fracture of body of scapula, left shoulder

Summary

A nondisplaced fracture of the body of the scapula refers to a break in the main, central portion of the left shoulder blade bone where the fractured fragments remain in their normal alignment. This condition involves damage to the scapula's body, the largest and most robust part of the bone, connecting the shoulder to the trunk. Nondisplaced fractures typically result from trauma and may cause pain and functional impairment, though the bone fragments stay in place without shifting.

Causes

Traumatic injury is the primary cause of nondisplaced fractures to the scapula's body. Common mechanisms include high-impact events such as motor vehicle accidents, falls from a significant height, or direct blows to the shoulder or back. Sports-related collisions or forceful impacts during physical activities may also result in 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

• 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 verify that the bone fragments are nondisplaced. Additional imaging, such as CT scans, may be ordered if the fracture is complex or if other injuries are suspected.

Treatment Options

Treatment for a nondisplaced fracture of the scapula's body often involves conservative management. This may include immobilization with a sling to support the arm and shoulder, pain management with medications, and physical therapy to restore strength and mobility once healing progresses. Severe or unstable fractures may require surgical intervention.

Prognosis and Follow-Up

Most nondisplaced scapular fractures heal well with conservative treatment, though recovery may take several weeks to months. Follow-up appointments are typically scheduled to monitor healing through imaging and assess functional recovery. Physical therapy is often recommended to restore full range of motion and strength.

Complications

Potential complications include chronic pain, limited shoulder mobility, or nonunion (failure of the bone to heal). In rare cases, nerve or blood vessel damage near the fracture site may occur, leading to additional symptoms or functional impairment.

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.
• Use proper techniques to prevent falls, especially in older adults.
• Strengthen shoulder and upper back muscles to improve stability.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, visible deformity, or inability to move the arm after an injury. Persistent pain, swelling, or difficulty with daily activities should also prompt a medical evaluation.

Tips for Medical Coders

When coding for S42.115, ensure documentation specifies a nondisplaced fracture of the scapula's body affecting the left shoulder. Verify that the fracture is not displaced and that the left side is clearly documented. Include details about the mechanism of injury and any associated symptoms to support the diagnosis.