Name of the Condition

• Displaced fracture of the lesser trochanter of the left femur, subsequent encounter for closed fracture with routine healing
• ICD-10 Code: S72.122D

Summary

• This condition refers to a broken segment of the lesser trochanter in the left femur that was initially sustained and is now being managed in a follow-up visit, with indications of typical healing under standard treatment conditions.

Causes

• Displaced fractures of the lesser trochanter typically arise from trauma, which might include falls or direct impact in cases involving high-energy injuries.
• It can also occur in individuals with weakened bones due to underlying conditions like osteoporosis.

Risk Factors

• Advanced age, especially in postmenopausal women at risk of osteoporosis.
• Participation in high-impact or contact sports.
• Conditions resulting in bone fragility, such as osteoporosis or metastatic bone disease.

Symptoms

• Pain in the hip or groin area, particularly worsened by movement.
• Swelling and bruising around the hip.
• Difficulty in weight-bearing or limping on the affected side.

Diagnosis

• Physical examination includes assessing range of motion and tenderness.
• Imaging like X-rays or CT scans to confirm the fracture's location and displacement.

Treatment Options

• Rest and avoidance of weight-bearing activities promote healing.
• Pain management through analgesics or anti-inflammatory medications.
• Physical therapy may be required to restore mobility.
• Surgical intervention might be necessary if conservative treatments do not suffice.

Prognosis and Follow-Up

• With routine healing, prognosis is generally good, with most patients regaining full function.
• Regular follow-up appointments are crucial to monitor healing progress and to adjust treatment plans as necessary.

Complications

• Delayed union or nonunion of the fracture.
• Development of osteoarthritis in the hip joint if improperly monitored.
• Chronic pain or mobility issues if rehabilitation is inadequate.

Lifestyle & Prevention

• Engaging in exercises that enhance balance and strength to prevent falls.
• Adequate calcium and vitamin D intake to support bone strength.
• Usage of protective gear during high-risk activities.

When to Seek Professional Help

• Persistent pain or swelling post-treatment.
• Inability to move the affected limb.
• Signs of infection, such as fever or unusual discharge from a wound site.

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS): aaos.org
• National Osteoporosis Foundation: nof.org

Tips for Medical Coders

• Ensure the correct side is documented as 'left femur' for accurate coding.
• Confirm the visit is for a subsequent encounter with routine healing.
• Double-check for appropriate encounter classification to avoid common errors.