S72.045M Nondisplaced fracture of base of neck of left femur, subsequent encounter for open fracture type I or II with nonunion

Name of the Condition

• Nondisplaced fracture of base of neck of left femur, subsequent encounter for open fracture type I or II with nonunion (S72.045M)

Summary

This condition involves a break in the upper portion of the left femur (thigh bone) at the base of the femoral neck, near the hip joint. The term "nondisplaced" indicates that the bone fragments remain in their normal anatomical position. The "open fracture type I or II" designation refers to a fracture where the skin is breached, with minimal or moderate soft tissue damage. The "subsequent encounter" modifier indicates this is a follow-up visit for an established fracture, and "nonunion" signifies that the bone has failed to heal properly after an expected period. This type of injury requires evaluation to determine the extent of the fracture and guide appropriate management.

Causes

High-impact trauma, such as falls or motor vehicle accidents, is a common cause. In older adults, particularly those with weakened bone density (e.g., osteoporosis), fractures may occur from minor trauma or low-impact events. Direct force to the hip or thigh region can also result in this injury. Nonunion may develop due to inadequate immobilization, poor blood supply to the fracture site, infection, or excessive movement during healing.

Risk Factors

• Advanced age, especially in individuals over 65
• Osteoporosis or other bone-weakening conditions
• Female gender, due to higher osteoporosis prevalence
• History of prior fractures or bone diseases
• Participation in high-risk activities (e.g., contact sports)
• Smoking or poor nutrition, which can impair bone healing
• Certain medical conditions (e.g., diabetes, vascular disease) that affect circulation

Symptoms

• Persistent or recurrent hip or groin pain
• Swelling, bruising, or tenderness around the hip
• Inability to bear weight on the affected leg
• Visible wound or opening at the fracture site (for open fractures)
• Limited range of motion in the hip joint
• Possible leg shortening or external rotation of the affected limb

Diagnosis

Physical examination to assess pain, mobility, and limb alignment. Imaging studies, including X-rays or CT scans, to visualize the fracture and assess for nonunion. Evaluation of the open wound (if present) to determine the extent of soft tissue damage. Assessment of healing progress through serial imaging and clinical follow-up.

Treatment Options

• Immobilization with a cast, brace, or traction to stabilize the fracture
• Surgical intervention, such as internal fixation (plates, screws) or bone grafting, to promote healing
• Antibiotics or wound care for open fractures to prevent infection
• Pain management with medications or physical therapy
• Nutritional support and smoking cessation to optimize bone healing

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture, the success of treatment, and the patient’s overall health. Nonunion may require additional interventions, such as surgery or bone stimulation techniques. Regular follow-up with imaging and clinical assessments is necessary to monitor healing progress. Long-term management may include physical therapy to restore mobility and strength.

Complications

• Nonunion or delayed healing
• Infection (especially with open fractures)
• Avascular necrosis (loss of blood supply to the femoral head)
• Post-traumatic arthritis of the hip joint
• Chronic pain or functional impairment
• Deep vein thrombosis or pulmonary embolism due to immobility

Lifestyle & Prevention

• Maintain a diet rich in calcium and vitamin D to support bone health
• Engage in weight-bearing exercises to strengthen bones
• Use assistive devices (e.g., canes, walkers) to prevent falls, especially in older adults
• Avoid high-risk activities that increase fracture risk
• Quit smoking and limit alcohol consumption, which can impair bone healing
• Regular bone density screenings for those at risk of osteoporosis

When to Seek Professional Help

Seek immediate medical attention if you experience severe hip pain, inability to bear weight, or visible signs of an open fracture (e.g., bleeding, exposed bone). Follow up with a healthcare provider if pain persists, swelling worsens, or you notice signs of infection (e.g., redness, pus, fever) after an injury.

Tips for Medical Coders

Document the laterality (left femur), fracture type (nondisplaced, open type I or II), encounter type (subsequent), and the presence of nonunion to accurately assign S72.045M. Ensure clinical notes specify the fracture’s anatomical location, soft tissue involvement, and healing status to support coding. Verify that the encounter is for a follow-up of an established fracture with nonunion, not an initial injury.