S42.152B Displaced fracture of neck of scapula, left shoulder, initial encounter for open fracture

Name of the Condition

• Displaced fracture of neck of scapula, left shoulder, initial encounter for open fracture

Summary

A displaced fracture of the neck of the scapula, left shoulder, involves a break in the narrow portion of the shoulder blade bone that connects to the shoulder joint, with the bone fragments shifted out of their normal alignment. This condition affects the left shoulder and is classified as an initial encounter for an open fracture, meaning the skin is breached, exposing the fracture site. The scapula's neck region is critical for shoulder stability and movement, and displacement can impact joint function.

Causes

Traumatic injury is the primary cause of this fracture. 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. The force required to displace the bone fragments and breach the skin typically indicates significant trauma.

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.
• Visible wound or open skin at the fracture site.
• In severe cases, visible deformity or instability.

Diagnosis

Diagnosis begins with a physical examination to assess pain, swelling, and open wound presence. Imaging studies, such as X-rays or CT scans, are used to confirm the fracture, assess displacement, and evaluate the extent of soft tissue damage. The open nature of the fracture is documented to guide treatment and infection risk management.

Treatment Options

Treatment focuses on stabilizing the fracture and managing the open wound. This may include wound cleaning, antibiotics to prevent infection, and immobilization with a sling or brace. Surgical intervention may be necessary for severe displacement or associated injuries. Pain management and physical therapy are often part of the recovery process.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture, displacement, and soft tissue damage. Most patients recover with proper treatment, though open fractures carry a higher risk of infection. Follow-up appointments monitor healing, wound care, and rehabilitation progress. Physical therapy may be recommended to restore shoulder function.

Complications

• Infection at the open fracture site.
• Nonunion or malunion of the fracture.
• Nerve or blood vessel damage.
• Chronic pain or limited shoulder mobility.
• Post-traumatic arthritis in the shoulder joint.

Lifestyle & Prevention

• Use protective gear during contact sports or high-risk activities.
• Maintain bone health through adequate calcium and vitamin D intake.
• Avoid falls by using assistive devices if balance is impaired.
• Follow safety protocols in high-risk environments, such as construction sites.

When to Seek Professional Help

Seek immediate medical attention if you experience severe shoulder pain, visible deformity, an open wound, or inability to move the arm after an injury. Prompt care is essential to reduce infection risk and optimize fracture healing.

Tips for Medical Coders

Document the fracture's displacement, laterality (left shoulder), and open nature clearly. Include details of the initial encounter and any associated injuries. Ensure the open fracture is distinguished from closed fractures, as this impacts coding and care management. Verify documentation aligns with the ICD-10-CM guidelines for accuracy.