2025 ICD-10-CM code S42.1
Fracture of scapula.
The seventh character of the ICD-10-CM code specifies the encounter type (initial or subsequent) and the healing status (routine, delayed, nonunion, malunion).
Medical necessity for treatment of a scapula fracture is established by the presence of a fracture confirmed through imaging, associated functional limitations, and the potential for complications if left untreated. The chosen treatment approach (surgical vs. non-surgical) must be justified based on the fracture's characteristics, the patient's overall health, and the potential for restoring optimal shoulder function.
Physicians, typically orthopedic surgeons, are responsible for diagnosing and managing scapula fractures. Diagnosis involves physical examination, X-rays, and potentially CT or MRI scans. Treatment varies depending on the severity and type of fracture, ranging from non-surgical immobilization with a sling and pain management to surgical intervention (ORIF) for complex or displaced fractures. Post-treatment care may include physical therapy to restore shoulder function.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the shoulder and upper arm (S40-S49)
In simple words: A broken shoulder blade, usually caused by a strong impact like a car accident or a fall. It's often very painful and can make it hard to move your arm.
A fracture of the scapula, commonly known as the shoulder blade, is a break in the flat, triangular bone located at the back of the shoulder. This bone connects the upper arm bone (humerus) to the collarbone (clavicle) and is crucial for shoulder movement and stability. Scapular fractures typically result from high-impact trauma such as motor vehicle accidents, falls from heights, or direct blows to the shoulder.They are frequently associated with other injuries to the shoulder, ribs, or chest.
Example 1: A 25-year-old male involved in a high-speed motor vehicle accident presents with severe right shoulder pain, swelling, and limited range of motion. Imaging reveals a displaced fracture of the scapular body.Due to the displacement, he undergoes ORIF to stabilize the fracture and restore proper shoulder alignment., A 60-year-old female falls from a ladder and lands on her left shoulder. She experiences pain, bruising, and difficulty moving her arm. X-rays confirm a non-displaced fracture of the scapular neck.She is treated non-surgically with a sling, pain medication, and physical therapy., A 30-year-old athlete sustains a direct blow to the shoulder during a football game.He complains of pain and tenderness, and imaging reveals a fracture of the acromion process of the scapula.Due to impingement symptoms, surgical intervention is considered to address the fracture and prevent long-term shoulder problems.
Thorough documentation for scapula fractures is essential for accurate coding and appropriate care. It should include: details of the traumatic event, physical exam findings (e.g., pain, swelling, limited range of motion, crepitus), imaging results (X-ray, CT, MRI), type and location of the fracture (e.g., body, neck, glenoid, acromion), associated injuries, treatment plan (surgical or non-surgical), and follow-up care (e.g., physical therapy).
** Scapular fractures are relatively uncommon and often result from high-energy trauma. Treatment decisions are guided by the specific fracture pattern and associated injuries.Most scapular fractures heal well with non-operative management, but certain types require surgery, particularly those involving the glenoid or significant displacement.
- Specialties:Orthopedic Surgery
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital, Other Place of Service