S62.015K Nondisplaced fracture of distal pole of navicular [scaphoid] bone of left wrist, subsequent encounter for fracture with nonunion

Name of the Condition

• Nondisplaced fracture of distal pole of navicular [scaphoid] bone of left wrist, subsequent encounter for fracture with nonunion

Summary

A nondisplaced fracture of the distal pole of the navicular (scaphoid) bone in the left wrist involves a break in the lower portion of this critical wrist bone, with the bone fragments remaining in their normal alignment. This code specifies a subsequent encounter for a fracture that has failed to heal (nonunion), requiring ongoing evaluation and management to address delayed healing or complications.

Causes

Typically results from a fall onto an outstretched hand (FOOSH). Can also occur due to direct trauma to the wrist, such as a blow or impact. May involve twisting injuries or high-force activities that stress the wrist. Nonunion may develop if initial treatment was inadequate, blood supply to the bone was compromised, or the fracture was not immobilized properly.

Risk Factors

• Participation in contact sports or activities with a high risk of falls.
• Osteoporosis or weakened bone structure, particularly in older adults.
• Previous wrist injuries or fractures that may compromise bone integrity.
• Delayed or inadequate initial treatment of the fracture.

Symptoms

• Persistent pain and tenderness localized to the wrist, especially near the base of the thumb.
• Swelling and bruising around the wrist area that may not resolve with time.
• Decreased range of motion or difficulty gripping objects.
• Possible numbness or tingling if nerves are affected.
• Symptoms that persist beyond the expected healing period for a fracture.

Diagnosis

Physical examination to assess pain, swelling, and wrist mobility. Imaging tests, such as X-rays, CT scans, or MRI, to evaluate fracture healing and detect nonunion. Additional tests may be ordered to assess blood flow to the bone or rule out infection.

Treatment Options

• Immobilization: Continued use of a cast or splint to stabilize the fracture and promote healing.
• Surgical intervention: Bone grafting, internal fixation, or other procedures to address nonunion.
• Physical therapy: Rehabilitation exercises to restore strength and mobility after treatment.
• Pain management: Medications or other therapies to control discomfort during recovery.

Prognosis and Follow-Up

Prognosis depends on the severity of the nonunion and response to treatment. Regular follow-up appointments are necessary to monitor healing progress. Full recovery may take several months, and some patients may experience long-term wrist stiffness or reduced function.

Complications

• Delayed or incomplete healing (nonunion) requiring additional treatment.
• Avascular necrosis (loss of blood supply to the bone).
• Chronic pain or arthritis in the wrist.
• Nerve damage leading to numbness or weakness.
• Infection (if surgical intervention is performed).

Lifestyle & Prevention

• Avoid high-impact activities or sports that risk wrist injury until fully healed.
• Use protective gear (e.g., wrist guards) during activities with fall risks.
• Maintain bone health through proper nutrition and exercise.
• Follow post-treatment guidelines to support healing and reduce complications.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, swelling, or deformity in the wrist. Contact your healthcare provider if symptoms worsen, or if you notice persistent numbness, tingling, or difficulty moving the wrist after treatment.

Tips for Medical Coders

Document the encounter as a subsequent visit for fracture care with explicit notation of nonunion. Include details on prior treatment, imaging results, and clinical findings supporting the nonunion diagnosis. Ensure documentation aligns with the code’s specificity for a left wrist fracture with delayed healing.