S62.025D Nondisplaced fracture of middle third of navicular [scaphoid] bone of left wrist, subsequent encounter for fracture with routine healing

Name of the Condition

• Nondisplaced fracture of middle third of navicular [scaphoid] bone of left wrist, subsequent encounter for fracture with routine healing

Summary

This condition describes a break in the middle third of the navicular (scaphoid) bone, a small bone in the left wrist near the base of the thumb. The fracture is nondisplaced, meaning the bone fragments remain in their normal position. This is a subsequent encounter, indicating the patient is receiving follow-up care for the fracture, which is healing as expected without complications.

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 healing progress. Documentation should indicate the fracture is nondisplaced and healing routinely.

Treatment Options

• Immobilization with a cast or splint to stabilize the bone during healing.
• Pain management with medications.
• Physical therapy to restore wrist strength and mobility once healing is advanced.
• Routine follow-up imaging to monitor healing.

Prognosis and Follow-Up

Healing time depends on the severity of the fracture and patient factors, typically 6–12 weeks for nondisplaced scaphoid fractures. Follow-up care ensures the fracture heals properly and function is restored. Routine healing implies no complications are expected.

Complications

• Delayed union or nonunion if healing is prolonged.
• Avascular necrosis (loss of blood supply to the bone) in severe cases.
• Chronic pain or arthritis if the fracture affects joint alignment.

Lifestyle & Prevention

• Avoid high-risk activities until fully healed.
• Use protective gear during sports or activities with fall risks.
• Maintain bone health through proper nutrition and exercise.

When to Seek Professional Help

• Increased pain, swelling, or bruising.
• Numbness or tingling in the hand or fingers.
• Difficulty moving the wrist or gripping objects.
• Signs of infection, such as redness, warmth, or fever.

Tips for Medical Coders

Document the fracture as nondisplaced and specify the left wrist. Indicate this is a subsequent encounter for fracture with routine healing. Ensure clinical notes support the healing status to justify the code.