S42.115A Nondisplaced fracture of body of scapula, left shoulder, initial encounter for closed fracture

Name of the Condition

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

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. The fracture is closed, meaning the skin is intact, and it is the initial encounter for this injury.

Causes

Traumatic injury is the primary cause of 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, such as X-rays or CT scans, are typically used to confirm the fracture and determine if it is nondisplaced. The closed nature of the fracture is also evaluated during the examination.

Treatment Options

Treatment for a nondisplaced fracture of the scapula body often involves conservative management, such as immobilization with a sling to support the arm and allow healing. Pain management with medications may be recommended. Physical therapy is usually initiated once initial healing occurs to restore strength and mobility. Surgical intervention is rarely needed for nondisplaced fractures unless other injuries are present.

Prognosis and Follow-Up

The prognosis for a nondisplaced scapula fracture is generally favorable, with most patients recovering fully over several weeks to months. Follow-up appointments are important to monitor healing and assess progress. Physical therapy may be continued to ensure optimal recovery of shoulder function.

Complications

While rare, complications can include nonunion (failure to heal), malunion (healing in an abnormal position), or persistent pain. Nerve or blood vessel injury near the fracture site is also possible but uncommon. Infection is not a typical concern for closed fractures.

Lifestyle & Prevention

Avoid high-risk activities or use protective gear during sports to reduce the risk of injury. 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 removing tripping hazards, are important for older adults.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, inability to move the arm, visible deformity, or signs of infection (e.g., fever, redness, drainage) after an injury. Persistent pain or limited mobility after initial treatment should also prompt a follow-up with a healthcare provider.

Tips for Medical Coders

Document the fracture as nondisplaced, specify the left shoulder, and confirm it is a closed fracture with no displacement. Ensure the encounter is coded as initial for a new injury. Include details about the mechanism of injury and any imaging results to support the diagnosis.