S42.265A Nondisplaced fracture of lesser tuberosity of left humerus, initial encounter for closed fracture

Name of the Condition

• Nondisplaced fracture of lesser tuberosity of left humerus, initial encounter for closed fracture (ICD Code: S42.265A)

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 is characterized by an intact bone alignment, meaning the bone fragments remain in their normal position. This type of fracture typically affects the attachment site of the subscapularis muscle and may impact shoulder function if not properly managed.

Causes

Nondisplaced fractures of the lesser tuberosity often result from direct trauma, such as a fall onto the shoulder or a forceful pull on the arm. High-impact injuries, including motor vehicle accidents or sports-related collisions, may also cause this type of fracture. Low-energy trauma can lead to this injury 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 tenderness at the fracture site.
• Limited range of motion in the shoulder.
• Difficulty lifting or moving the arm.

Diagnosis

Physical examination to assess pain, range of motion, and tenderness. Imaging tests, including X-rays, to confirm the fracture and verify nondisplacement. CT scans or MRIs may be used for detailed assessment of soft tissue involvement or to rule out associated injuries.

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 is rarely needed for nondisplaced fractures but may be considered if instability or associated injuries are present.

Prognosis and Follow-Up

Most nondisplaced fractures heal well with conservative treatment, and full function often returns within several weeks to months. Follow-up appointments may include repeat imaging to monitor healing and assessments of range of motion. Adherence to rehabilitation guidelines is important to prevent stiffness or weakness.

Complications

• Delayed union or nonunion of the fracture.
• Shoulder stiffness or reduced range of motion.
• Nerve or blood vessel injury, though rare in nondisplaced cases.
• Post-traumatic arthritis if the joint is affected.

Lifestyle & Prevention

• Use protective gear during high-risk activities like sports.
• Maintain bone health through a balanced diet and regular exercise.
• Avoid falls by modifying the home environment (e.g., removing tripping hazards).
• Strengthen shoulder muscles to improve stability.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, visible deformity, or inability to move the arm. Contact a healthcare provider if symptoms worsen or do not improve with initial treatment, or if you develop numbness, tingling, or changes in skin color.

Tips for Medical Coders

Document the fracture as nondisplaced and specify the left humerus. Note the initial encounter for a closed fracture, as these details are critical for accurate coding. Ensure the record includes confirmation of the fracture type (nondisplaced) and absence of open wounds or complications to support the code assignment.