S42.251S Displaced fracture of greater tuberosity of right humerus, sequela

Name of the Condition

• Displaced fracture of greater tuberosity of right humerus, sequela (ICD-10 Code: S42.251S)

Summary

This condition represents a displaced fracture of the greater tuberosity of the right humerus that has reached the sequela phase. The greater tuberosity is a bony prominence on the upper end of the humerus (upper arm bone) near the shoulder joint. In the sequela phase, the fracture has healed, but residual effects or complications persist, such as chronic pain, limited mobility, or deformity.

Causes

The sequela phase follows an initial traumatic injury to the shoulder, such as a fall, direct blow, or forceful muscle contraction. The original fracture displaced the bone fragment, and healing resulted in long-term consequences.

Risk Factors

• Prior history of shoulder trauma or fracture.
• Incomplete healing or malunion of the original fracture.
• Underlying conditions affecting bone or soft tissue recovery, such as poor circulation or chronic inflammation.

Symptoms

• Chronic shoulder pain or discomfort.
• Reduced range of motion in the shoulder or arm.
• Persistent swelling or tenderness at the fracture site.
• Possible visible deformity or muscle weakness.

Diagnosis

Clinical evaluation to assess residual symptoms and functional limitations. Imaging, such as X-rays or MRI, may be used to evaluate healed bone structure and identify ongoing issues like arthritis or soft tissue damage.

Treatment Options

• Physical Therapy: To improve strength, flexibility, and mobility.
• Pain Management: Medications or injections to address chronic discomfort.
• Assistive Devices: Slings or braces to support the shoulder during activity.
• Surgical Intervention: In cases of severe deformity or functional impairment.

Prognosis and Follow-Up

Prognosis depends on the extent of residual damage and adherence to rehabilitation. Regular follow-up with a healthcare provider is recommended to monitor recovery and adjust treatment as needed.

Complications

• Chronic shoulder pain or stiffness.
• Post-traumatic arthritis.
• Nerve or blood vessel damage from the original injury.
• Reduced shoulder function affecting daily activities.

Lifestyle & Prevention

• Avoid activities that strain the shoulder, such as heavy lifting.
• Engage in low-impact exercises to maintain mobility.
• Use proper techniques during sports or physical tasks to prevent re-injury.

When to Seek Professional Help

Seek care if symptoms worsen, new pain or swelling occurs, or functional limitations increase. Prompt evaluation is important to address complications or adjust treatment.

Tips for Medical Coders

This code is used for the sequela phase of a displaced fracture of the greater tuberosity of the right humerus. Documentation should specify the residual effects or complications, such as chronic pain or limited mobility, to support the sequela designation. Ensure the code aligns with the patient’s current clinical status and prior fracture history.