S42.265S Nondisplaced fracture of lesser tuberosity of left humerus, sequela

Name of the Condition

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

Summary

This condition represents a nondisplaced fracture of the lesser tuberosity, a bony prominence on the left humerus near the shoulder joint, with residual effects from a prior injury. The fracture is characterized by minimal separation of bone fragments, and the "sequela" designation indicates ongoing consequences or complications following the initial injury. The lesser tuberosity serves as an attachment point for the subscapularis muscle, and fractures here may impact shoulder function or joint stability.

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. The sequela designation implies that the current condition is a result of a previous fracture, with residual effects persisting after the acute phase.

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.
• Inadequate healing or rehabilitation following the initial injury.

Symptoms

• Persistent pain in the shoulder or upper arm.
• Reduced range of motion or stiffness in the shoulder.
• Muscle weakness or atrophy around the shoulder.
• Possible deformity or tenderness at the fracture site.

Diagnosis

Physical examination to assess pain, range of motion, and residual deformity. Imaging tests, including X-rays, to evaluate the fracture site and healing progress. CT scans or MRIs may be used for detailed assessment of soft tissue or joint involvement.

Treatment Options

• Physical therapy to restore range of motion and strength.
• Pain management with medications or modalities.
• Surgical intervention if residual displacement or instability is present.
• Assistive devices, such as slings or braces, to support healing.

Prognosis and Follow-Up

Prognosis depends on the extent of residual damage and adherence to rehabilitation. Most patients experience improved function with appropriate treatment, though some may have persistent limitations. Regular follow-up with imaging and clinical assessments is recommended to monitor healing and address complications.

Complications

• Chronic pain or stiffness.
• Muscle weakness or atrophy.
• Joint instability or arthritis.
• Nerve or vascular damage in severe cases.

Lifestyle & Prevention

• Engage in regular strength and flexibility exercises to support shoulder health.
• Use protective gear during high-risk activities.
• Maintain bone health through diet and exercise.
• Follow post-injury rehabilitation protocols to minimize residual effects.

When to Seek Professional Help

Seek medical attention if symptoms worsen, new pain or deformity develops, or if there is difficulty moving the arm. Prompt evaluation is important for managing complications or adjusting treatment plans.

Tips for Medical Coders

Document the sequela status clearly, including the relationship to the prior fracture and any residual effects. Ensure that clinical notes specify the nature of the ongoing consequences to support the sequela code. Verify that the fracture is nondisplaced and localized to the lesser tuberosity of the left humerus.