S72.025K Nondisplaced fracture of epiphysis (separation) (upper) of left femur, subsequent encounter for closed fracture with nonunion

Name of the Condition

• Nondisplaced fracture of epiphysis (separation) (upper) of left femur, subsequent encounter for closed fracture with nonunion

Summary

This condition involves a nondisplaced fracture or separation of the epiphysis (growth plate) in the upper portion of the left femur, with nonunion indicating failure of the fracture to heal properly. It typically results from trauma and requires evaluation to assess the extent of the injury and guide management. The closed fracture means the skin remains intact, while nonunion may necessitate additional interventions to promote healing.

Causes

High-impact trauma, such as falls, sports injuries, or motor vehicle accidents. Direct force to the hip or thigh region.

Risk Factors

• Adolescence, as growth plates are more vulnerable during development
• Participation in high-impact activities or contact sports
• Underlying bone conditions that weaken structural integrity
• Poor blood supply to the fracture site
• Inadequate immobilization or premature weight-bearing

Symptoms

• Persistent pain and swelling in the hip or thigh area
• Difficulty bearing weight on the affected leg
• Bruising or tenderness at the injury site
• Limited range of motion in the hip joint
• Possible instability or deformity if nonunion progresses

Diagnosis

Physical examination to assess pain, swelling, and mobility. Imaging studies, such as X-rays or MRI, to visualize the fracture and evaluate alignment. Additional scans may be used to assess bone healing and rule out other complications.

Treatment Options

• Surgical intervention, such as bone grafting or internal fixation, to promote union
• Prolonged immobilization with casting or bracing to support healing
• Physical therapy to restore strength and mobility after healing
• Medications to manage pain and inflammation

Prognosis and Follow-Up

Recovery depends on the success of treatment and adherence to follow-up care. Nonunion may require extended rehabilitation or additional procedures. Regular monitoring with imaging is necessary to assess healing progress.

Complications

• Chronic pain or instability
• Avascular necrosis (loss of blood supply to the bone)
• Malunion or deformity
• Increased risk of future fractures
• Long-term mobility limitations

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider
• Use protective gear during sports or activities with fall risk
• Maintain a balanced diet rich in calcium and vitamin D to support bone health
• Follow post-treatment guidelines to prevent re-injury

When to Seek Professional Help

• Persistent or worsening pain despite treatment
• New swelling, bruising, or deformity
• Inability to bear weight on the affected leg
• Signs of infection, such as fever or increased redness at the injury site

Tips for Medical Coders

Document the fracture type (closed), location (left femur, upper epiphysis), and the presence of nonunion. Specify that this is a subsequent encounter to reflect ongoing management. Ensure clinical notes support the nonunion diagnosis and any interventions performed.