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Orthopedics & Traumatology

Scapular Fracture, Body, Left, Closed, Initial Encounter

ICD-10 Code
S42.112A

Standardized diagnosis for Scapular Fracture, Body, Left, Closed, Initial Encounter.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with acute left shoulder pain following a high-energy trauma. Reports localized tenderness over the scapular body, exacerbated by shoulder movement and deep inspiration. No associated neurovascular deficits reported. Denies numbness, tingling, or weakness in the distal upper extremity.

Clinical Examination Findings

Inspection of the left shoulder reveals localized swelling and ecchymosis over the scapular region. Palpation demonstrates significant bony tenderness over the scapular body. Range of motion is severely limited by pain. Neurovascular examination of the left upper extremity is intact, with palpable radial and ulnar pulses and normal capillary refill.

Treatment Protocol

Initial management includes immobilization of the left shoulder using a sling and swathe for comfort. Pain management initiated with non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics. Patient advised to apply ice packs for 20 minutes every 4 hours. Orthopedic follow-up scheduled for repeat imaging and assessment of fracture stability.

Detailed clinical guide coming soon.