S62.355B Nondisplaced fracture of shaft of fourth metacarpal bone, left hand, initial encounter for open fracture

Name of the Condition

• Nondisplaced fracture of shaft of fourth metacarpal bone, left hand, initial encounter for open fracture

Summary

A nondisplaced fracture of the shaft of the fourth metacarpal bone in the left hand, with an open fracture and initial encounter, refers to a break in the midsection of the bone connecting the ring finger to the wrist, where the bone fragments remain aligned. The fracture involves an open wound, meaning the bone has pierced the skin, and this is the first encounter for this specific injury.

Causes

Direct trauma, such as a fall or blow to the hand. Sports-related injuries or accidents. Penetrating injuries that break the skin and underlying bone.

Risk Factors

• Participation in contact sports or high-impact activities.
• Reduced bone density or osteoporosis.
• Occupational hazards involving manual labor or use of tools.
• History of prior hand fractures.

Symptoms

• Pain and swelling in the left hand.
• Tenderness or bruising around the affected area.
• Difficulty moving the fingers or hand.
• Open wound at the fracture site.
• Possible deformity or misalignment (less common with nondisplaced fractures).

Diagnosis

Physical examination by a healthcare provider to assess tenderness, swelling, deformity, or open wound. Imaging tests, such as X-rays, to confirm the fracture and evaluate its extent. Assessment of the open wound for contamination or infection risk.

Treatment Options

• Wound cleaning and debridement to reduce infection risk.
• Immobilization with a cast or splint to promote healing.
• Pain management using over-the-counter or prescription medications.
• Antibiotics to prevent infection due to the open fracture.
• Physical therapy to restore mobility and strength after healing.
• Surgery may be required for severe cases or if the wound is extensive.

Prognosis and Follow-Up

Most nondisplaced fractures heal well with proper immobilization and care. Follow-up appointments are necessary to monitor healing and adjust treatment. Physical therapy may be recommended to restore full function. Open fractures require close monitoring for signs of infection.

Complications

• Infection at the open wound site.
• Delayed healing or nonunion.
• Stiffness or reduced mobility in the hand.
• Nerve or tendon damage near the fracture.
• Chronic pain.

Lifestyle & Prevention

• Use protective gear during sports or high-risk activities.
• Maintain bone health through proper nutrition and exercise.
• Avoid repetitive stress on the hand.
• Practice safe techniques in manual labor or tool use.

When to Seek Professional Help

Seek immediate medical attention if there is an open wound, severe pain, swelling, or inability to move the hand. Contact a healthcare provider if symptoms worsen or do not improve with initial treatment.

Tips for Medical Coders

Document the location (left hand, fourth metacarpal), fracture type (nondisplaced), wound status (open), and encounter type (initial) to ensure accurate coding. Include details about the open fracture, such as wound size or contamination, if available, to support code specificity.