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

Name of the Condition

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

Summary

A nondisplaced fracture of the shaft of the fourth metacarpal bone in the left hand, with subsequent encounter for malunion, 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 healed in a non-anatomical position. This code indicates a follow-up visit for a fracture that has healed improperly, without significant displacement of the fragments.

Causes

Direct trauma, such as a fall or blow to the hand. Sports-related injuries or accidents. Inadequate immobilization during initial healing.

Risk Factors

• Participation in contact sports or high-impact activities.
• Reduced bone density or osteoporosis.
• Occupational hazards involving manual labor.
• Delayed or improper initial fracture management.

Symptoms

• Persistent pain or discomfort in the left hand.
• Swelling or tenderness around the affected area.
• Limited range of motion in the ring finger or hand.
• Visible or palpable deformity at the fracture site.
• Functional impairment, such as difficulty gripping objects.

Diagnosis

Physical examination by a healthcare provider to assess tenderness, swelling, or deformity. Imaging tests, such as X-rays, to confirm malunion and evaluate the extent of healing. Review of prior treatment and immobilization history.

Treatment Options

• Orthopedic referral for evaluation of malunion severity.
• Pain management with medications or physical therapy.
• Possible surgical intervention to correct alignment, if clinically indicated.
• Custom splinting or bracing to support the hand during healing.

Prognosis and Follow-Up

Prognosis depends on the degree of malunion and functional impact. Follow-up care may include regular imaging to monitor healing and functional assessments. Long-term outcomes can range from full recovery to persistent stiffness or weakness, depending on treatment and adherence to rehabilitation.

Complications

• Chronic pain or discomfort.
• Reduced hand function or grip strength.
• Increased risk of future fractures in the affected area.
• Potential need for additional surgical intervention.

Lifestyle & Prevention

• Use protective gear during high-risk activities.
• Maintain bone health through proper nutrition and exercise.
• Follow post-fracture care instructions to ensure proper healing.
• Avoid activities that stress the healing bone until cleared by a healthcare provider.

When to Seek Professional Help

Seek care if pain worsens, swelling increases, or hand function declines. Consult a provider if deformity is noticeable or if there are signs of infection, such as redness, warmth, or drainage.

Tips for Medical Coders

Document the presence of malunion and the subsequent encounter status clearly. Include details on prior treatment, imaging results, and clinical assessment of healing to support code assignment. Ensure documentation reflects the ongoing nature of care for this fracture complication.