S42.264A Nondisplaced fracture of lesser tuberosity of right humerus, initial encounter for closed fracture

Name of the Condition

• Nondisplaced fracture of lesser tuberosity of right humerus, initial encounter for closed fracture (ICD Code: S42.264A)

Summary

This condition involves a nondisplaced fracture of the lesser tuberosity, a bony prominence on the front of the right humerus near the shoulder joint. The fracture is characterized by an intact bone structure without separation of fragments, which may affect the attachment of the subscapularis tendon and surrounding structures. The term "initial encounter" indicates this is the first episode of care for the fracture, and "closed fracture" means the skin remains intact.

Causes

Nondisplaced fractures of the lesser tuberosity typically result from direct trauma, such as falls onto the shoulder, motor vehicle accidents, or high-impact sports injuries. Low-energy trauma may also cause this type of fracture in individuals with weakened bones.

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.

Symptoms

• Intense pain in the shoulder or upper arm.
• Swelling, bruising, and visible deformity at the fracture site.
• Inability to move the arm or bear weight.
• Numbness or tingling in the hand or fingers if nerve involvement occurs.

Diagnosis

Physical examination to assess pain, range of motion, and deformity. Imaging tests, including X-rays, to visualize the fracture pattern and displacement. CT scans or MRIs may be used for detailed assessment of complex fractures or soft tissue damage.

Treatment Options

• Immobilization with a sling or brace to support healing.
• Pain management with medications or ice therapy.
• Physical therapy to restore strength and mobility once healing progresses.
• Surgical intervention if the fracture becomes displaced or fails to heal.

Prognosis and Follow-Up

Most nondisplaced fractures heal well with conservative treatment, though recovery may take several weeks to months. Follow-up appointments monitor healing progress and adjust treatment as needed. Full function often returns, but some residual stiffness or weakness may persist.

Complications

• Delayed healing or nonunion if the fracture does not stabilize.
• Nerve or blood vessel damage near the fracture site.
• Post-traumatic arthritis in the shoulder joint over time.
• Chronic pain or reduced range of motion.

Lifestyle & Prevention

• Strengthen shoulder muscles through targeted exercises.
• Use protective gear during high-risk activities.
• Maintain bone health with calcium and vitamin D.
• Avoid falls by modifying home environments for safety.

When to Seek Professional Help

Seek immediate care for severe pain, visible deformity, or inability to move the arm. Contact a healthcare provider if symptoms worsen or do not improve with initial treatment.

Tips for Medical Coders

Document the fracture as nondisplaced, specify the right humerus, and confirm the initial encounter for a closed fracture. Ensure clinical notes support the absence of displacement and the closed nature of the injury to justify the code.