ICD 10 CM S02.412B | Description & Clinical Information

ICD 10 S02.412B describes a specific type of fracture, known as a LeFort type II fracture, which occurs as a result of injury or trauma and involves the separation of the maxilla or upper jaw from the nasal skeleton, and this code is used to indicate the initial encounter with a patient for an open fracture.

Official Description Of S02.412B

The ICD 10 CM book defines ICD 10 code S02.412B as:

Clinical Information

The diagnosis describes by ICD 10 CM S02.412B pertains to a type of facial fracture known as the LeFort II fracture. This type of facial fracture can result in a disfigurement of the facial bones, soft tissue swelling, and bleeding or the formation of a blood clot. Additionally, the skin may discolor due to bruising, and there may be a flattened look of the face.

Medical providers primarily diagnose LeFort II fractures based on a patient’s history, where the mechanism of injury is taken into consideration. These medical professionals also examine the facial bones and maxilla during a physical exam. To confirm a diagnosis, imaging techniques like X-rays and computed tomography scans may be utilized.

Treatment for LeFort II fractures requires stabilizing the patient and treating any associated problems such as injury to the airway, cervical spine, chest, or abdomen. Any excess bleeding must be halted as well. Providers may also perform a LeFort osteotomy or fracture repair and suturing.

The maxilla and its appendages are the most affected in LeFort II fractures, which are caused by a strong blow to the middle of the face. Although the third major wrenching fracture remains the most difficult diagnosis and was only isolated in 1916 by Rene LeFort, the LeFort II fracture may involve additional complex injuries to the maxilla and craniofacial structures.

LeFort II fractures are relatively uncommon, yet can lead to severe aesthetic and functional abnormalities. It can take about six to eight weeks for the facial bones to fully heal, with patients experiencing swelling and discomfort during the recovery period.

Severe cases of LeFort II fractures can cause difficulty in breathing or eating, along with vision and speech problems. Therefore, early identification and management of this condition is imperative. Surgery is often the recommended treatment for complicated LeFort II fractures, as they can result in severe, life-threatening complications if left untreated.

In summary, a LeFort II fracture is a severe facial injury that requires adequate medical care, diagnosis, and treatment. The patient history, physical exam, and imaging techniques are crucial steps taken in diagnosing and treating such injuries. With a prompt diagnosis and adequate care, most patients recover fully from this condition, and any associated problems can be resolved effectively.