S42.155 Nondisplaced fracture of neck of scapula, left shoulder

Name of the Condition

• Nondisplaced fracture of neck of scapula, left shoulder

Summary

A nondisplaced fracture of the neck of the scapula, left shoulder, refers to a break in the narrow portion of the shoulder blade bone that connects the body of the scapula to the glenoid fossa (shoulder joint), where the bone fragments remain in their normal anatomical alignment. This condition affects the left shoulder and may impact shoulder stability and function due to the neck's role in supporting the glenoid fossa. Nondisplaced fractures typically result from lower-energy trauma compared to displaced fractures.

Causes

Traumatic injury is the primary cause of fractures to the scapular neck. Common mechanisms include falls from a significant height, motor vehicle accidents, 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 left shoulder may be affected due to the direction of impact or body positioning during the injury.

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 left shoulder is specifically evaluated to identify the location and extent of the injury. Additional tests may be performed to rule out associated injuries to surrounding structures.

Treatment Options

Treatment for a nondisplaced fracture of the scapular neck often involves conservative management, such as immobilization with a sling to support the shoulder and allow healing. Pain management with medications may be recommended. Physical therapy is typically initiated once initial healing occurs to restore range of motion and strength. Surgical intervention is rarely needed for nondisplaced fractures unless there are complications.

Prognosis and Follow-Up

The prognosis for a nondisplaced fracture of the scapular neck is generally favorable, with most patients recovering full function over time. Follow-up appointments are important to monitor healing and adjust treatment as needed. Physical therapy plays a key role in restoring shoulder mobility and strength. Most patients can return to normal activities within several weeks to months, depending on the severity of the injury.

Complications

While rare, complications may include nonunion (failure of the bone to heal), malunion (healing in an abnormal position), or persistent pain. Nerve or vascular injury is uncommon but possible with severe trauma. Chronic shoulder instability or arthritis may develop in some cases, particularly if the fracture affects joint alignment.

Lifestyle & Prevention

To reduce the risk of fractures, engage in regular weight-bearing exercise to maintain bone density. Use proper safety equipment during sports or high-risk activities. Avoid falls by modifying the home environment to reduce tripping hazards. If you have osteoporosis, follow your healthcare provider’s recommendations for bone health.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, swelling, or deformity after an injury. Contact your healthcare provider if pain persists or worsens, or if you notice numbness, tingling, or weakness in the arm. Follow up with your provider if symptoms do not improve with initial treatment.

Tips for Medical Coders

When coding for a nondisplaced fracture of the neck of the scapula, left shoulder, use ICD-10-CM code S42.155. Ensure documentation specifies the location (left shoulder) and that the fracture is nondisplaced. Include details about the mechanism of injury, symptoms, and any imaging results to support the diagnosis. Verify that the fracture is not associated with displacement or other complications, as this may affect coding.