Understanding Distal Clavicle Fracture diagnosis, treatment, and documentation? Find information on Lateral Clavicle Fracture or Acromial End Clavicle Fracture, including clinical findings, ICD-10 codes, medical coding guidelines, and healthcare resources. Learn about distal clavicle fracture types, surgical and non-surgical management, rehabilitation, and recovery. This resource helps healthcare professionals with accurate clinical documentation and coding for Distal Clavicle Fractures.
Also known as
Fracture of clavicle
Covers fractures of the clavicle, including the distal end.
Fracture of shoulder and upper arm
Includes various fractures around the shoulder and upper arm.
Injuries, poisoning and certain other consequences of external causes
Encompasses a broad range of injury-related diagnoses, including fractures.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the distal clavicle fracture closed?
Yes
Is the fracture displaced?
No
Is the fracture displaced?
When to use each related code
| Description |
|---|
| Fracture of the outer end of the clavicle. |
| Fracture of the middle part of the clavicle. |
| Fracture of the inner end of the clavicle. |
Missing or incorrect laterality (right, left, unspecified) can lead to claim rejections and inaccurate data reporting. CDI should query for clarity.
Documentation must specify if the fracture is displaced or non-displaced as it impacts code selection and reimbursement. CDI review is crucial.
Accurate coding requires distinguishing between open and closed fractures. Insufficient documentation may lead to coding errors and compliance risks. CDI can clarify documentation.
Q: How can I differentiate between a distal clavicle fracture, AC joint separation, and a distal radius fracture based on physical exam findings and initial imaging?
A: Differentiating between a distal clavicle fracture, acromioclavicular (AC) joint separation, and a distal radius fracture requires a thorough clinical evaluation and imaging. Distal clavicle fractures often present with localized pain and swelling over the lateral end of the clavicle, with pain exacerbated by shoulder movement. AC joint separations will show tenderness over the AC joint itself, often with visible deformity depending on the grade of separation. Distal radius fractures, while located in the forearm, can sometimes present with referred pain higher in the arm and should be considered if the mechanism of injury involves a fall onto an outstretched hand. Initial radiographs of the affected area (shoulder for clavicle/AC, wrist for radius) are crucial. While plain films can often identify distal clavicle and radius fractures, they might not fully characterize the extent of AC joint injury. Explore how further imaging, such as dedicated AC joint views or MRI, may be necessary to define ligamentous injury in suspected AC separations. Consider implementing a standardized examination protocol for shoulder injuries to ensure thorough assessment and appropriate imaging choices.
Q: What are the current best practice non-operative and operative management options for Neer Type II distal clavicle fractures, and how do I choose between them?
A: Neer Type II distal clavicle fractures, involving displacement without significant comminution, can often be treated non-operatively. Non-operative management typically involves immobilization with a sling or figure-of-eight brace for 4-6 weeks, combined with early range-of-motion exercises once pain allows. However, factors like significant displacement, shortening of the clavicle, or high patient activity levels may warrant surgical intervention. Operative options include plate fixation, intramedullary fixation, or coracoclavicular ligament reconstruction. The choice between operative and non-operative management depends on factors such as fracture displacement, patient age, activity level, and occupation. Learn more about the latest evidence-based guidelines regarding optimal management for Neer Type II distal clavicle fractures to inform decision-making and provide individualized care.
Patient presents with right shoulder pain following a fall onto an outstretched hand. Physical examination reveals point tenderness over the distal clavicle, with localized swelling and ecchymosis. Pain is exacerbated with shoulder range of motion, particularly abduction and forward flexion. There is no gross deformity noted. Distal clavicle fracture is suspected. Radiographic imaging of the right shoulder, including AP, lateral, and Zanca views, was ordered to confirm the diagnosis and assess for displacement. Differential diagnosis includes acromioclavicular joint separation and contusion. Preliminary diagnosis of lateral clavicle fracture is consistent with the mechanism of injury and clinical findings. Pending radiographic confirmation, treatment options including conservative management with a sling, analgesics, and physical therapy will be discussed. Surgical intervention may be considered if significant displacement or comminution is present. Patient education regarding distal clavicle fracture recovery, potential complications, and follow-up care will be provided. ICD-10 code S42.009A, unspecified fracture of the right clavicle, distal end, initial encounter for closed fracture, is anticipated pending radiographic confirmation. CPT codes for evaluation and management services will be determined based on complexity of the encounter. Return to activity will be dictated by pain tolerance and healing progression.