S62.025S Nondisplaced fracture of middle third of navicular [scaphoid] bone of left wrist, sequela

Name of the Condition

• Nondisplaced fracture of middle third of navicular [scaphoid] bone of left wrist, sequela

Summary

This condition represents a healed or healing nondisplaced fracture of the middle third of the navicular (scaphoid) bone in the left wrist, documented as a sequela. The fracture fragments remain in their normal anatomical position, and the sequela designation indicates residual effects or complications following the initial injury. The scaphoid bone is critical for wrist stability and movement, and fractures in this location may result from trauma or stress to the wrist.

Causes

Typically results from a prior 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. The sequela designation applies to the residual effects of the original fracture.

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

• Persistent pain or discomfort at the base of the thumb.
• Swelling or bruising around the wrist area.
• Limited wrist movement or difficulty gripping objects.
• Possible numbness or tingling if nerves are affected.
• Residual functional impairment from the healed fracture.

Diagnosis

Physical examination to assess pain, swelling, and wrist mobility. Imaging tests, such as X-rays, CT scans, or MRI, to evaluate the healed fracture and any residual effects. Documentation of the sequela status is based on clinical findings and the history of the original injury.

Treatment Options

• Pain management with analgesics or anti-inflammatory medications.
• Physical therapy to restore wrist function and strength.
• Immobilization with a splint or cast if residual instability is present.
• Surgical intervention if complications, such as nonunion or avascular necrosis, develop.

Prognosis and Follow-Up

Most nondisplaced scaphoid fractures heal well with appropriate treatment. Follow-up care focuses on monitoring for complications, such as delayed union or arthritis. Regular assessments of wrist function and imaging may be recommended to ensure proper healing.

Complications

• Avascular necrosis (loss of blood supply to the bone).
• Nonunion (failure of the fracture to heal).
• Post-traumatic arthritis in the wrist joint.
• Persistent pain or functional limitations.

Lifestyle & Prevention

• Avoid high-impact activities that stress the wrist until fully healed.
• Use protective gear during sports or activities with fall risks.
• Maintain bone health through proper nutrition and exercise.
• Follow rehabilitation guidelines to restore strength and mobility.

When to Seek Professional Help

• Increasing 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 or drainage.

Tips for Medical Coders

Document the sequela status clearly, indicating the residual effects of the original fracture. Ensure the left wrist and middle third of the navicular bone are specified. Include details of the healing process or complications to support the sequela designation.