S42.265 Nondisplaced fracture of lesser tuberosity of left humerus

Name of the Condition

• Nondisplaced fracture of lesser tuberosity of left humerus (ICD Code: S42.265)

Summary

This condition involves a nondisplaced fracture of the lesser tuberosity, a bony prominence on the front of the left humerus near the shoulder joint. The fracture does not involve significant separation of bone fragments, preserving the attachment of the subscapularis tendon and surrounding structures.

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

• Conservative management with immobilization using a sling or brace.
• Pain management with medications or ice therapy.
• Physical therapy to restore range of motion and strength.
• Surgical intervention if displacement occurs or if conservative treatment fails.

Prognosis and Follow-Up

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

Complications

• Delayed healing or nonunion if the fracture is not properly immobilized.
• Nerve or blood vessel damage near the fracture site.
• Post-traumatic arthritis in the shoulder joint.
• Chronic pain or reduced mobility.

Lifestyle & Prevention

• Use protective gear during high-risk activities.
• Maintain bone health with calcium and vitamin D.
• Avoid falls by modifying home environments (e.g., removing tripping hazards).
• Engage in regular strength training to support bone density.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, inability to move the arm, visible deformity, or signs of nerve involvement (e.g., numbness, tingling). Follow up with a healthcare provider if symptoms worsen or do not improve with initial treatment.

Tips for Medical Coders

Document the fracture as nondisplaced and specify the left humerus. Include details on the mechanism of injury, imaging findings, and treatment approach to support accurate coding. Ensure the diagnosis aligns with clinical documentation to avoid coding errors.