S72.136K Nondisplaced apophyseal fracture of unspecified femur, subsequent encounter for closed fracture with nonunion

Name of the Condition

• Nondisplaced apophyseal fracture of unspecified femur, subsequent encounter for closed fracture with nonunion

Summary

A nondisplaced apophyseal fracture of the unspecified femur is a break in the apophysis, a growth plate area on the femur where tendons or ligaments attach, with the bone fragments remaining in their normal anatomical position. This subsequent encounter code applies to a closed fracture (no skin breakage) that has developed nonunion, meaning the bone has failed to heal properly after an initial injury.

Causes

Apophyseal fractures commonly result from direct trauma, such as falls or high-impact injuries, particularly in adolescents during growth spurts. Nonunion may occur due to inadequate immobilization, poor blood supply to the fracture site, or excessive movement before healing is complete.

Risk Factors

• Adolescence, especially during periods of rapid growth.
• Participation in high-impact sports or activities.
• History of previous injuries to the hip or thigh.
• Underlying bone conditions that weaken the apophysis.
• Factors that impair healing, such as smoking or diabetes.

Symptoms

• Persistent localized pain at the hip or thigh, often worsened by movement or pressure.
• Swelling, tenderness, or bruising around the affected area.
• Difficulty bearing weight on the leg.
• Possible limping or altered gait.
• Symptoms that do not improve with standard healing timelines.

Diagnosis

Physical examination to assess pain, swelling, and tenderness. Imaging studies, including X-rays or MRI, to confirm the fracture and evaluate for nonunion. Additional tests may assess bone healing or blood flow to the site.

Treatment Options

Treatment focuses on promoting bone healing and may include immobilization with a cast or brace, physical therapy to restore strength and mobility, and in some cases, surgical intervention to stabilize the fracture. Pain management and activity modification are also part of the plan.

Prognosis and Follow-Up

Prognosis depends on the severity of the nonunion and response to treatment. Regular follow-up with imaging is typically required to monitor healing progress. Most patients can expect gradual improvement with appropriate care, though recovery may take longer than for a healing fracture.

Complications

• Chronic pain or discomfort.
• Persistent difficulty with weight-bearing or mobility.
• Increased risk of future fractures in the affected area.
• Potential need for surgical intervention if nonunion persists.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider.
• Follow prescribed immobilization and activity restrictions.
• Maintain a balanced diet rich in calcium and vitamin D to support bone health.
• Use proper protective equipment during sports or activities.

When to Seek Professional Help

Seek medical attention if pain worsens, swelling increases, or mobility declines. Contact a provider if symptoms do not improve with treatment or if new symptoms, such as fever or increased redness, develop.

Tips for Medical Coders

Document the encounter as a subsequent visit for a closed fracture with nonunion. Ensure clinical notes specify the fracture type (nondisplaced), location (unspecified femur), and the presence of nonunion. Include details on treatment provided and any imaging results to support coding accuracy.