S42.261K Displaced fracture of lesser tuberosity of right humerus, subsequent encounter for fracture with nonunion

Name of the Condition

• Displaced fracture of lesser tuberosity of right humerus, subsequent encounter for fracture with nonunion (ICD Code: S42.261K)

Summary

This condition involves a displaced fracture of the lesser tuberosity, a bony prominence on the right humerus near the shoulder joint. The fracture has failed to heal (nonunion) during follow-up care. The lesser tuberosity serves as an attachment point for the subscapularis tendon, and nonunion may affect muscle function or joint stability.

Causes

Displaced fractures of the lesser tuberosity typically result from direct trauma, such as a fall onto the shoulder, forceful arm pull, or high-impact injuries like motor vehicle accidents. Nonunion may occur due to inadequate immobilization, poor blood supply, or excessive movement during healing.

Risk Factors

• Advanced age and osteoporosis, which reduce bone density.
• Participation in contact sports or activities with a high risk of falls.
• Previous fractures or bone disorders that weaken the skeletal structure.
• Smoking or poor nutrition, which impair bone healing.

Symptoms

• Persistent pain in the shoulder or upper arm, often worsening with movement.
• Swelling or bruising that does not resolve over time.
• Limited arm mobility or stiffness.
• Possible deformity at the fracture site if displacement persists.

Diagnosis

Physical examination to assess pain, range of motion, and deformity. Imaging tests, including X-rays, to confirm nonunion by showing a persistent fracture line with no bridging bone. CT scans or MRIs may be used to evaluate bone healing and surrounding structures.

Treatment Options

• Surgical intervention, such as open reduction and internal fixation, to stabilize the fracture.
• Bone grafting to promote healing in cases of severe nonunion.
• Physical therapy to restore strength and mobility after treatment.
• Pain management and activity modification to support recovery.

Prognosis and Follow-Up

Prognosis depends on the success of treatment and adherence to rehabilitation. Follow-up care involves regular imaging to monitor healing and functional assessments to track recovery. Long-term outcomes may include residual stiffness or reduced strength.

Complications

• Chronic pain or instability in the shoulder joint.
• Nerve or blood vessel damage near the fracture site.
• Infection or hardware-related issues if surgery is performed.
• Reduced quality of life due to limited arm function.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider.
• Maintain a balanced diet rich in calcium and vitamin D to support bone health.
• Use protective gear during sports or activities with fall risks.
• Follow post-injury guidelines to minimize complications.

When to Seek Professional Help

Seek care if pain worsens, swelling increases, or mobility declines. Contact a provider immediately for new deformity, numbness, or signs of infection (e.g., redness, fever).

Tips for Medical Coders

Document the encounter as a subsequent visit for fracture with nonunion. Include details on imaging findings, treatment plans, and clinical assessments to support the diagnosis. Ensure documentation reflects the nonunion status and any interventions performed.