Learn about left shoulder dislocation (ICD-10 code S43.02) diagnosis, clinical documentation, and medical coding. Find information on left glenohumeral dislocation and dislocated left shoulder including symptoms, treatment, and recovery. This resource provides healthcare professionals with essential information for accurate and efficient documentation and coding of a dislocated left shoulder.
Also known as
Dislocation of shoulder
Covers dislocations of the left and right shoulder joint.
Injuries to the shoulder and upper arm
Includes fractures, dislocations, and other injuries to the shoulder and upper arm.
Injury, poisoning and certain other consequences of external causes
Encompasses a wide range of injuries and external causes.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the left shoulder dislocation traumatic?
Yes
Initial encounter?
No
Atraumatic or unspecified?
When to use each related code
| Description |
|---|
| Left shoulder out of socket |
| Partial left shoulder dislocation |
| Shoulder separation (left) |
Coding requires specifying left shoulder. Omitting laterality can lead to inaccurate billing and claims rejection.
Documentation must specify type (anterior, posterior, inferior, etc.) for accurate ICD-10 coding and reimbursement.
Coding should capture any associated fractures, nerve damage, or rotator cuff tears to reflect the full severity.
Q: What are the best evidence-based clinical examination techniques for diagnosing a left shoulder dislocation in a patient presenting with acute shoulder pain and suspected instability?
A: Diagnosing a left shoulder dislocation requires a thorough clinical examination incorporating several key techniques. Begin by visually inspecting the shoulder for obvious deformity, such as a prominent acromion or a hollow appearance below it. Palpation can help identify the humeral head's position, which will be displaced anteriorly in most dislocations. Assess for neurovascular compromise by checking radial pulse, capillary refill, and sensation in the hand. Evaluate range of motion, noting any limitations or pain. The apprehension test, where the arm is abducted and externally rotated, can elicit apprehension in patients with anterior instability suggestive of a prior dislocation. Radiographic imaging, including anteroposterior, lateral, and scapular Y views, is essential to confirm the diagnosis, determine the dislocation type, and rule out associated fractures. Explore how integrating dynamic ultrasound during the physical examination can provide real-time visualization of joint instability. Consider implementing a standardized examination protocol for shoulder pain to ensure consistent and comprehensive assessments. Learn more about the specific radiographic findings associated with different types of shoulder dislocations.
Q: How can clinicians differentiate between a left shoulder subluxation and a complete left shoulder dislocation, and what are the implications for management strategies?
A: Differentiating between a left shoulder subluxation and a complete dislocation is crucial for determining appropriate management. In a subluxation, the humeral head partially dislocates from the glenoid fossa but spontaneously relocates. Patients may report a feeling of the shoulder “slipping out” or “popping.” A complete dislocation involves the humeral head completely dislocating from the glenoid and remaining dislocated. This presents with more significant pain, deformity, and loss of function. Clinical examination, including assessment for apprehension and range of motion, can provide clues. However, radiographic imaging is necessary to confirm the diagnosis and assess for any associated bone or soft tissue injuries. Subluxations may be managed conservatively with physical therapy focused on strengthening rotator cuff muscles and improving shoulder stability. Complete dislocations require prompt reduction, often followed by immobilization and a period of rehabilitation. Explore how advanced imaging techniques, such as MRI arthrography, can help identify subtle labral tears or other soft tissue damage common in recurrent instability. Learn more about the various reduction techniques for shoulder dislocations and the potential complications associated with each.
Patient presents with complaints consistent with left shoulder dislocation. Onset of symptoms occurred [Date of onset] during [Mechanism of injury - e.g., fall, sports injury, direct trauma]. Patient reports experiencing acute left shoulder pain, described as [Character of pain - e.g., sharp, throbbing, aching], as well as significant limitation of movement and instability in the affected joint. Physical examination reveals [Visible deformity - e.g., anterior shoulder fullness, prominent clavicle], tenderness to palpation over the left glenohumeral joint, and positive apprehension sign. Neurovascular assessment of the left upper extremity shows [Sensory and motor function assessment - e.g., intact radial, ulnar, and median nerve function; 5/5 strength in the hand and wrist]. Differential diagnosis includes shoulder subluxation, rotator cuff tear, clavicle fracture, and acromioclavicular joint separation. Radiographic imaging, specifically a left shoulder X-ray, was obtained and confirmed the diagnosis of left glenohumeral dislocation, demonstrating [Radiographic findings - e.g., anterior displacement of the humeral head]. Initial treatment included closed reduction of the dislocation under [Type of anesthesia - e.g., conscious sedation], followed by application of a [Type of immobilization - e.g., sling and swathe]. Patient tolerated the procedure well. Post-reduction X-rays confirmed successful relocation of the humeral head. Patient education provided regarding pain management, activity modification, and follow-up care. Referral to orthopedics for further evaluation and management, including potential physical therapy, is recommended. ICD-10 code S43.011A (Dislocation of left shoulder, initial encounter) is documented.