S43.121A Dislocation of right acromioclavicular joint, 100%-200% displacement, initial encounter

Name of the Condition

• Dislocation of Right Acromioclavicular Joint, 100%-200% Displacement, Initial Encounter

Summary

This condition involves a complete dislocation of the right acromioclavicular (AC) joint, where the clavicle is displaced from the acromion of the scapula by 100% to 200% of its normal width. It typically results from trauma and may cause pain, instability, or restricted movement in the shoulder. The "initial encounter" designation indicates this is the first time the patient is seeking care for this specific injury.

Causes

Traumatic events like falls, direct blows to the shoulder, or forceful movements can cause this dislocation. Sports injuries, motor vehicle accidents, or falls are common triggers.

Risk Factors

• Participation in contact sports or activities with high fall risk.
• Previous shoulder injuries or ligamentous instability.
• Age-related degeneration or connective tissue disorders.
• Occupations requiring repetitive arm or shoulder movements.

Symptoms

• Pain and tenderness around the top of the right shoulder.
• Visible deformity or swelling over the acromioclavicular joint.
• Limited range of motion in the shoulder.
• Sensation of the joint "popping out" or feeling unstable.

Diagnosis

Diagnosis typically involves a physical examination to assess tenderness, deformity, and range of motion. Imaging tests like X-rays may be used to confirm displacement and rule out fractures.

Treatment Options

• Non-surgical treatments such as rest, ice, and physical therapy to restore movement and strength.
• Surgical options in severe cases to realign the joint and stabilize it.

Prognosis and Follow-Up

Most patients recover with appropriate treatment, though recovery time varies. Follow-up care may include physical therapy to regain strength and mobility. Long-term outcomes depend on the severity of the injury and adherence to treatment plans.

Complications

• Chronic shoulder instability or pain.
• Nerve or blood vessel damage in severe cases.
• Arthritis in the AC joint over time.

Lifestyle & Prevention

• Use protective gear during contact sports.
• Avoid high-risk activities if you have a history of shoulder injuries.
• Strengthen shoulder muscles through regular exercise.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, visible deformity, or inability to move the shoulder after an injury.

Tips for Medical Coders

Document the side (right), displacement percentage (100%-200%), and encounter type (initial) to ensure accurate coding. Include details about trauma mechanism, physical exam findings, and imaging results to support the diagnosis.