Learn about Dislocated Right Shoulder diagnosis, including clinical documentation, medical coding, and ICD-10 codes for Right Shoulder Dislocation and Glenohumeral Dislocation. Find information on diagnosis, treatment, and healthcare resources related to a Dislocated Right Shoulder for accurate medical records and efficient billing. This resource provides relevant information for physicians, coders, and other healthcare professionals dealing with shoulder dislocations.
Also known as
Dislocation of shoulder
Covers dislocations of the shoulder joint, including traumatic and atraumatic.
Dislocation of jaw
Includes dislocations of the temporomandibular joint (TMJ).
Injuries to shoulder and upper arm
Encompasses various injuries like fractures, dislocations, and sprains of the shoulder and upper arm.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the right shoulder dislocation traumatic?
Yes
Initial encounter?
No
Atraumatic dislocation?
When to use each related code
| Description |
|---|
| Right shoulder out of socket. |
| Partial right shoulder dislocation. |
| Shoulder separation AC joint. |
Coding and documentation must clearly specify 'right' shoulder to avoid ambiguity and ensure accurate reimbursement. Missing laterality can lead to claim denials.
Documentation should specify the type of dislocation (anterior, posterior, inferior) for proper ICD-10 coding and to reflect the severity and complexity accurately.
Failing to document associated injuries (fractures, rotator cuff tears) with shoulder dislocation can lead to undercoding and lost revenue. Thorough documentation is crucial.
Q: What are the best evidence-based conservative management strategies for an acute first-time right shoulder dislocation in a young adult patient with no significant comorbidities?
A: Conservative management of a first-time acute right shoulder dislocation in a young adult without comorbidities typically involves closed reduction followed by immobilization. Current best practice suggests immobilization in external rotation for a period ranging from 1-3 weeks, based on factors such as patient stability and comfort. Early mobilization within a pain-free range of motion is crucial for preventing stiffness and promoting recovery. This can include gentle, supervised exercises focusing on rotator cuff strengthening and scapular stabilization. Consider implementing a phased rehabilitation program that progresses from passive to active-assisted to active range of motion and strengthening exercises. Explore how incorporating proprioceptive neuromuscular facilitation (PNF) techniques can further enhance functional recovery. However, individual patient factors should always guide treatment decisions. Learn more about tailoring rehabilitation protocols to specific patient needs and the latest research on optimal immobilization durations.
Q: How can I differentiate between a right shoulder dislocation and other common shoulder injuries like rotator cuff tears or AC joint separations during clinical examination?
A: Differentiating a right shoulder dislocation from other shoulder pathologies like rotator cuff tears or AC joint separations requires a thorough clinical examination. With a dislocation, you'll often observe a visibly deformed shoulder, with the humeral head displaced anteriorly, inferiorly, or posteriorly. Palpation may reveal an empty glenoid fossa. Unlike a rotator cuff tear, which typically presents with pain and weakness during specific movements, a dislocation will restrict the entire range of motion due to pain and mechanical blockage. AC joint separations, characterized by localized pain and swelling over the AC joint, can be distinguished from shoulder dislocations by the absence of humeral head displacement. While imaging studies like X-rays are essential for confirming the diagnosis and assessing for associated fractures, careful clinical examination, including assessing the patient's history, range of motion, and palpation findings, can often provide strong initial clues. Consider implementing standardized physical examination protocols to ensure consistent and accurate assessments. Explore how advanced imaging modalities like MRI can provide detailed information on soft tissue injuries in complex cases.
Patient presents with complaints of right shoulder pain and instability following a fall onto an outstretched hand. On examination, the patient exhibits right shoulder deformity consistent with anterior shoulder dislocation. Palpation reveals tenderness over the anterior glenohumeral joint and decreased range of motion secondary to pain and guarding. Neurovascular examination of the right upper extremity, including assessment of radial pulse and sensation in the median, ulnar, and radial nerve distributions, is within normal limits. Apprehension test and relocation test are positive, further supporting the diagnosis of right shoulder dislocation. Radiographic imaging of the right shoulder was performed, confirming anterior glenohumeral dislocation with no associated fractures. Differential diagnoses considered included rotator cuff tear, labral tear, and acromioclavicular joint injury. Given the clinical presentation and imaging findings, the diagnosis of right shoulder dislocation was established. Closed reduction of the right shoulder dislocation was performed under procedural sedation, with successful relocation confirmed clinically and radiographically. The patient was placed in a shoulder immobilizer and provided with pain management medication and discharge instructions, including follow-up with orthopedic surgery for further evaluation and management, including physical therapy for rehabilitation. ICD-10 code S93.01 (Dislocation of right shoulder) is appropriate for this encounter. CPT codes for the closed reduction and subsequent immobilization will be documented separately based on the specific procedures performed.