S72.062E Displaced articular fracture of head of left femur, subsequent encounter for open fracture type I or II with routine healing

Name of the Condition

• Displaced articular fracture of head of left femur, subsequent encounter for open fracture type I or II with routine healing

Summary

A displaced articular fracture of the head of the left femur involves a break in the femoral head (the rounded upper portion of the thigh bone that forms part of the hip joint) with the fracture fragments shifted out of their normal alignment. This injury disrupts the joint surface, which is critical for smooth movement. The fracture is classified as open (type I or II), meaning there is a wound communicating with the fracture site, and it is documented as a subsequent encounter, indicating follow-up care for an established injury. The healing is routine, suggesting normal progress without complications. Prompt evaluation is necessary to assess the extent of displacement, wound status, and guide ongoing management.

Causes

High-impact trauma, such as falls or motor vehicle accidents. Low-impact trauma in individuals with weakened bones (e.g., osteoporosis). Direct force to the hip region resulting in an open wound.

Risk Factors

• Advanced age, particularly in those over 65
• Osteoporosis or other bone density disorders
• Female gender, due to higher osteoporosis prevalence
• History of prior fractures or bone diseases
• Participation in high-risk activities (e.g., contact sports)
• Conditions that impair wound healing or increase fracture risk

Symptoms

• Sudden, severe hip or groin pain
• Inability to bear weight on the affected leg
• Swelling, bruising, or tenderness around the hip
• Leg shortening or external rotation of the affected limb
• Limited range of motion in the hip joint
• Open wound over the hip or thigh (for open fracture types)

Diagnosis

Physical examination to assess pain, mobility, limb alignment, and wound status. Imaging studies, including X-rays or CT scans, to visualize the fracture, displacement, and healing progress. Evaluation of wound characteristics (size, depth, contamination) for open fractures.

Treatment Options

• Immobilization with a brace or cast to stabilize the fracture during healing
• Pain management with analgesics or anti-inflammatory medications
• Wound care for open fractures (cleaning, dressing changes, possible antibiotics)
• Physical therapy to restore strength and range of motion once healing allows
• Surgical intervention (e.g., internal fixation) if displacement or instability persists
• Monitoring for signs of infection or delayed healing

Prognosis and Follow-Up

Prognosis is generally favorable with routine healing, though outcomes depend on fracture severity, patient age, and adherence to treatment. Follow-up care focuses on assessing healing progress, managing pain, and restoring function. Regular imaging may be used to confirm bone union. Long-term monitoring for arthritis or avascular necrosis (loss of blood supply to the femoral head) is important.

Complications

• Infection (especially with open fractures)
• Nonunion or delayed union of the fracture
• Avascular necrosis of the femoral head
• Post-traumatic arthritis of the hip joint
• Chronic pain or stiffness
• Leg length discrepancy

Lifestyle & Prevention

• Fall prevention strategies (e.g., home modifications, balance exercises) for older adults
• Bone health optimization (adequate calcium, vitamin D, and weight-bearing exercise)
• Avoidance of high-risk activities that increase fracture risk
• Prompt treatment of open wounds to reduce infection risk
• Smoking cessation and limiting alcohol, as these impair bone healing

When to Seek Professional Help

Seek immediate medical attention for severe hip pain, inability to bear weight, visible deformity, or signs of infection (e.g., fever, increased redness, drainage). Follow up with a healthcare provider if pain worsens, swelling persists, or mobility does not improve as expected.

Tips for Medical Coders

Document the laterality (left femur), fracture type (displaced articular), encounter type (subsequent), open fracture classification (type I or II), and healing status (routine) to accurately assign this code. Ensure clinical documentation supports the open fracture designation and confirms routine healing without complications.