S62.025A Nondisplaced fracture of middle third of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture

Name of the Condition

• Nondisplaced fracture of middle third of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture

Summary

This condition involves a break in the middle third of the navicular (scaphoid) bone, a small bone in the wrist near the base of the thumb, on the left side. The fracture is nondisplaced, meaning the bone fragments remain in their normal position. It is classified as a closed fracture, with no break in the skin, and is documented as an initial encounter for treatment.

Causes

Typically results from a fall onto an outstretched hand (FOOSH). Can occur due to direct trauma to the wrist, such as a blow or impact. May also result from twisting injuries or high-impact activities that stress the wrist.

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 have compromised bone integrity.

Symptoms

• Pain and tenderness at the base of the thumb.
• Swelling and bruising around the wrist area.
• Limited wrist movement or difficulty gripping objects.
• Possible numbness or tingling if nerves are affected.

Diagnosis

Physical examination to assess pain, swelling, and wrist mobility. Imaging tests, such as X-rays, CT scans, or MRI, to visualize the fracture and confirm it is nondisplaced. Documentation must specify the location (middle third), side (left), and that it is a closed fracture with no displacement.

Treatment Options

• Immobilization with a cast or splint to stabilize the bone.
• Pain management with medications.
• Close monitoring for healing, as nondisplaced fractures may require less invasive intervention than displaced ones.

Prognosis and Follow-Up

Healing time depends on the severity of the fracture and patient factors. Most nondisplaced fractures heal with immobilization, but follow-up imaging may be needed to confirm union. Physical therapy may be recommended to restore strength and mobility after healing.

Complications

• Delayed union or nonunion of the fracture.
• Avascular necrosis (loss of blood supply to the bone) due to the scaphoid’s unique blood supply.
• Arthritis in the wrist joint if the fracture does not heal properly.
• Persistent pain or stiffness.

Lifestyle & Prevention

• Use protective gear during high-risk activities (e.g., wrist guards in sports).
• Maintain bone health through adequate calcium and vitamin D intake.
• Avoid falls by using assistive devices if balance is impaired.
• Strengthen wrist muscles through targeted exercises.

When to Seek Professional Help

Seek immediate care if pain is severe, swelling worsens, or there is numbness/tingling. Follow up with a healthcare provider if symptoms do not improve with initial treatment or if new symptoms (e.g., fever, increased redness) develop.

Tips for Medical Coders

Document the fracture as nondisplaced, specify the left wrist, and confirm it is a closed fracture with no displacement. Ensure the encounter is coded as initial (A) to reflect the first episode of care. Include details about imaging results and clinical findings to support the nondisplaced classification.