S49.029S Salter-Harris Type II physeal fracture of upper end of humerus, unspecified arm, sequela

Name of the Condition

• Salter-Harris Type II physeal fracture of upper end of humerus, unspecified arm, sequela (ICD-10 Code: S49.029S)

Summary

This code describes a Salter-Harris Type II fracture involving the growth plate (physeal) at the upper end of the humerus, with the arm side unspecified, classified as a sequela. This type of fracture occurs when the growth plate and a portion of the metaphysis separate from the rest of the bone, typically in children and adolescents due to the relative weakness of the physis during development. The sequela designation indicates residual effects following the healing of the fracture.

Causes

Trauma, such as a fall onto an outstretched hand or a direct blow to the shoulder, is the primary cause. These injuries often occur during sports, play, or accidents involving forceful arm movement.

Risk Factors

• Age (most common in children and adolescents with open growth plates)
• Participation in high-impact sports or activities
• Prior growth plate injuries

Symptoms

• Chronic pain or discomfort at the shoulder or upper arm
• Limited range of motion or stiffness
• Visible deformity in severe cases
• Difficulty moving the arm

Diagnosis

Diagnosis relies on a physical examination to assess pain, swelling, and range of motion, combined with imaging studies like X-rays to visualize the fracture and confirm its location at the growth plate. A detailed patient history, including the mechanism of injury and prior treatment, is essential to determine if residual effects are present.

Treatment Options

Treatment focuses on managing residual symptoms and may include physical therapy to improve range of motion and strength, pain management, and monitoring for long-term complications. In some cases, surgical intervention may be considered if deformity or functional impairment is significant.

Prognosis and Follow-Up

Prognosis depends on the severity of the initial injury and the effectiveness of treatment. Most patients recover with minimal long-term effects, but some may experience persistent stiffness or deformity. Regular follow-up with a healthcare provider is recommended to monitor healing and address any ongoing issues.

Complications

• Chronic pain or discomfort
• Limited range of motion or stiffness
• Visible deformity
• Potential for growth disturbances in severe cases

Lifestyle & Prevention

• Engage in regular physical activity to maintain strength and flexibility
• Use protective equipment during sports or high-impact activities
• Avoid activities that place excessive stress on the arm or shoulder
• Follow recommended rehabilitation protocols after injury

When to Seek Professional Help

Seek medical attention if you experience persistent pain, swelling, or difficulty moving the arm, or if you notice any new deformity or changes in function. Early evaluation can help prevent long-term complications.

Tips for Medical Coders

This code is used for a sequela of a Salter-Harris Type II physeal fracture of the upper end of the humerus, unspecified arm. Documentation should clearly indicate the residual effects of the fracture, such as chronic pain, limited range of motion, or deformity, and confirm that the condition is a sequela rather than an active fracture. Ensure the encounter type and arm specificity are accurately recorded to support appropriate coding.