R10.9 - Unspecified abdominal pain

Clinical Definition

A closed fracture of both bones in the forearm (radius and ulna). The break occurs at the shaft/diaphyseal portion of both bones and involves no penetration of the skin.

Documentation Requirements

• Must clearly document:

  • Involvement of BOTH radius and ulna

  • Location specifically at the shaft/diaphysis

  • Confirmation of closed fracture (skin intact)

  • Laterality (right vs. left)

  • Episode of care (initial, subsequent, sequela)

  • Healing status (routine, delayed, nonunion, malunion)

  • Any associated complications

  • Mechanism of injury/cause

Common Synonyms

• "Broken forearm"

• "Broken arm in two places"

• "Double forearm fracture"

• "Nightstick fracture" (when defensive injury)

Coding Conflicts

Excludes1:

• Single bone fractures of radius alone

• Single bone fractures of ulna alone

• Open fractures of radius and ulna

• Fractures at wrist or elbow joints

Scribing.io Automation

Our AI scribe automatically:

• Identifies mentions of both radius and ulna in same context

• Flags mentions of "shaft" or "diaphyseal" location

• Captures injury mechanism from patient history

• Recognizes laterality terms

• Monitors healing progression notes

• Tags wound descriptions confirming closed status

Remember to dictate "closed fracture of both radius and ulna shafts" rather than just "forearm fracture" for optimal coding accuracy.