S62.355K Nondisplaced fracture of shaft of fourth metacarpal bone, left hand, subsequent encounter for fracture with nonunion

Name of the Condition

• Nondisplaced fracture of shaft of fourth metacarpal bone, left hand, subsequent encounter for fracture with nonunion

Summary

A nondisplaced fracture of the shaft of the fourth metacarpal bone in the left hand, with nonunion and subsequent encounter, refers to a break in the midsection of the bone connecting the ring finger to the wrist where the bone fragments remain aligned but have failed to heal properly. This is a follow-up visit for a fracture that did not unite during the expected healing period.

Causes

Direct trauma, such as a fall or blow to the hand. Sports-related injuries or accidents. Inadequate immobilization or premature weight-bearing. Poor blood supply to the fracture site.

Risk Factors

• Participation in contact sports or high-impact activities.
• Reduced bone density or osteoporosis.
• Smoking or poor nutrition affecting bone healing.
• Displaced fractures or open fractures that increase healing challenges.
• Certain medical conditions like diabetes or autoimmune disorders.

Symptoms

• Persistent pain at the fracture site.
• Swelling or tenderness that does not improve over time.
• Limited mobility or stiffness in the hand.
• Possible clicking or grinding sensation with movement.
• No visible deformity, but discomfort during use.

Diagnosis

Physical examination by a healthcare provider to assess tenderness, swelling, or functional limitations. Imaging tests, such as X-rays or CT scans, to confirm nonunion and evaluate bone alignment. Review of prior treatment and healing history.

Treatment Options

• Prolonged immobilization with a cast or splint to encourage healing.
• Bone stimulation therapies, such as ultrasound or electrical stimulation.
• Surgical intervention, including bone grafting or internal fixation, if nonunion persists.
• Pain management with medications or physical therapy to restore function.

Prognosis and Follow-Up

Healing may be prolonged, and some cases require surgical intervention. Regular follow-up visits monitor progress, with imaging to assess bone union. Full recovery depends on the success of treatment and adherence to rehabilitation.

Complications

• Chronic pain or arthritis in the affected joint.
• Permanent loss of mobility or strength.
• Infection (if surgery is performed).
• Need for additional interventions if nonunion recurs.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a provider.
• Follow prescribed immobilization and weight-bearing restrictions.
• Maintain a balanced diet rich in calcium and vitamin D to support bone health.
• Use protective gear during sports or manual labor.

When to Seek Professional Help

Seek care if pain worsens, swelling increases, or mobility declines. Contact a provider if signs of infection (redness, pus, fever) appear or if the fracture site feels unstable.

Tips for Medical Coders

Document the fracture's status (nondisplaced, nonunion) and the encounter type (subsequent) clearly. Include details on prior treatments, imaging results, and clinical findings to support the code. Ensure the left-hand specification and nonunion are explicitly noted in the record.