ICD 10 CM S42.239B | Description & Clinical Information

ICD 10 S42.239B describes a type of fracture that occurs in the surgical neck of an unspecified humerus, where three out of the four parts of the humerus, including the humeral head, humeral shaft, greater tuberosity, or lesser tuberosity, are completely or incompletely separated due to trauma from a high impact fall, sports injury, or motor vehicle accident, and the provider has not documented whether the condition affects the right or left humerus at the initial encounter for a fracture that is exposed through a tear or laceration of the skin caused by the fracture fragments or external trauma.

Official Description Of S42.239B

The ICD 10 CM book defines ICD 10 code S42.239B as:

When To Use S42.239B

The diagnosis described by the ICD 10 CM S42.239B code pertains to a type of shoulder injury known as a three-part fracture of the surgical neck of the humerus, which can lead to a range of unpleasant symptoms. This type of fracture can result in pain in the affected shoulder as well as an inability to perform daily activities due to a decreased range of motion. Swelling and stiffness in the affected area can also occur, which can be troublesome for patients. The muscles of the arm and upper back may become weakened, and patients may experience tingling or numbness, particularly in the arms and fingers.

Medical providers arrive at a diagnosis by evaluating the patient’s history of trauma and performing a physical examination. They may also take a blood sample to evaluate the levels of calcium and vitamin D in the body, and carry out neurological tests to assess muscle strength, sensation, and reflexes. In addition, imaging techniques such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), electromyography, nerve conduction tests, and bone scans may be utilized to diagnose the condition accurately.

Depending on the severity of the fracture, treatment options may vary. For stable fractures, surgery is typically not required, but an unstable fracture may need fixation and nerve decompression surgery. Patients may also be fitted with a sling, splint or cast to immobilize the shoulder, in addition to undergoing physical therapy with strengthening exercises. Medications such as steroids, analgesics, and nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to help alleviate pain. In some cases, thrombolytics or anticoagulants may be given to reduce the risk of blood clots.

Closed reduction, sometimes with fixation, or possibly an open reduction and internal fixation (ORIF) procedure might also be recommended, depending on the severity of the fracture. In severe cases, shoulder replacement surgery with a prosthesis might be necessary to restore function to the shoulder.

In conclusion, medical coding students should always remember that the diagnosis indicated by the ICD 10 CM S42.239B code represents a serious and potentially life-altering medical condition. Prompt and accurate diagnosis, coupled with an appropriate treatment plan, offers patients the best chance for a positive outcome.