S42.252D Displaced fracture of greater tuberosity of left humerus, subsequent encounter for fracture with routine healing

Name of the Condition

• Displaced fracture of greater tuberosity of left humerus, subsequent encounter for fracture with routine healing (ICD-10 Code: S42.252D)

Summary

This condition represents a displaced fracture of the greater tuberosity, a bony prominence on the upper end of the left humerus (upper arm bone) near the shoulder joint. The fracture is characterized by the separation of the bone fragment from its normal anatomical position. This code is used for a subsequent encounter when the fracture is healing routinely, indicating the patient is in a later phase of recovery.

Causes

Typically results from direct trauma to the shoulder, such as a fall onto the shoulder, a direct blow, or forceful muscle contraction (e.g., during sports or lifting). Low-energy trauma may also cause the injury in individuals with weakened bones.

Risk Factors

• Participation in contact sports or activities with a high risk of shoulder injury.
• Osteoporosis or weakened bone density, which increases susceptibility to fractures.
• Advanced age, which may reduce bone integrity.
• Previous shoulder injuries or conditions that compromise bone strength.

Symptoms

• Acute pain localized to the shoulder or upper arm.
• Swelling, bruising, and tenderness over the fracture site.
• Difficulty moving the shoulder or lifting the arm.
• Possible visible deformity or prominence at the shoulder.

Diagnosis

Physical examination to assess pain, swelling, and range of motion. Imaging tests, such as X-rays, are used to confirm the fracture and evaluate displacement. CT scans or MRIs may be ordered for detailed assessment of complex fractures.

Treatment Options

Treatment may include immobilization with a sling, pain management, and physical therapy to restore range of motion and strength. Surgical intervention is rarely needed for isolated greater tuberosity fractures but may be considered for significant displacement or associated injuries.

Prognosis and Follow-Up

With routine healing, most patients recover full shoulder function over several weeks to months. Follow-up care focuses on monitoring healing progress and guiding rehabilitation. Routine healing implies no complications or delayed union.

Complications

Potential complications include nonunion, malunion, shoulder stiffness, or rotator cuff dysfunction. Infection or nerve injury is rare but possible with surgical intervention.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider.
• Engage in strength training to support bone and muscle health.
• Use proper techniques for lifting or sports to reduce injury risk.
• Maintain bone health through adequate nutrition and exercise.

When to Seek Professional Help

Seek care if pain worsens, swelling increases, or movement does not improve with treatment. Contact a provider immediately for signs of infection (e.g., fever, redness) or new numbness/weakness.

Tips for Medical Coders

This code is specific to a subsequent encounter for a displaced fracture of the greater tuberosity of the left humerus with routine healing. Documentation should confirm the fracture’s displacement, laterality (left), and that healing is progressing without complications. Ensure the encounter is classified as "subsequent" and that routine healing is explicitly noted.