S43.132A Dislocation of left acromioclavicular joint, greater than 200% displacement, initial encounter

Name of the Condition

• Dislocation of Left Acromioclavicular Joint, Greater Than 200% Displacement, Initial Encounter

Summary

This condition involves a complete dislocation of the left acromioclavicular (AC) joint, where the clavicle is displaced from the acromion of the scapula by more than 200%. It typically results from significant trauma and may cause severe pain, instability, or restricted movement in the shoulder. The "initial encounter" designation indicates this is the first time the patient is receiving 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

• Severe pain and tenderness around the top of the 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.
• Surgical intervention for severe cases or persistent instability.
• Pain management with medications or injections.
• Immobilization with a sling or brace to support healing.

Prognosis and Follow-Up

Recovery depends on the severity of the injury and treatment approach. Most patients experience improved function with appropriate care, but some may have residual stiffness or instability. Follow-up appointments monitor healing and guide rehabilitation.

Complications

• Chronic shoulder instability or recurrent dislocations.
• Nerve or blood vessel damage in severe cases.
• Post-traumatic arthritis in the joint over time.
• Limited range of motion or persistent pain.

Lifestyle & Prevention

• Use protective gear during high-risk activities.
• Strengthen shoulder muscles through targeted exercises.
• Avoid falls by maintaining balance and using assistive devices if needed.
• Modify activities to reduce strain on the shoulder joint.

When to Seek Professional Help

Seek immediate medical attention if you experience severe shoulder pain, visible deformity, or inability to move the arm after an injury. Prompt evaluation is important to prevent complications and ensure proper treatment.

Tips for Medical Coders

Document the side (left), degree of displacement (>200%), and encounter type (initial) clearly in the medical record. Ensure clinical notes support the diagnosis and specify any imaging or physical exam findings that confirm the displacement.