Name of the Condition

• Salter-Harris Type I physeal fracture of upper end of left femur

Summary

• A Salter-Harris Type I fracture is a type of injury to the growth plate (physis) in children or adolescents. This specific fracture involves the upper end of the left femur, where the growth plate has separated without involving the bone shaft. It's a common injury in children due to falls or sports.

Causes

• Typically caused by acute trauma such as falls, accidents, or sports-related injuries where a force is transmitted across the growth plate.

Risk Factors

• Common in children and adolescents who are active in sports.
• More frequent during growth spurts when the growth plates are weaker relative to the surrounding tissues.

Symptoms

• Pain and tenderness around the hip or upper thigh.
• Swelling and possible difficulty walking or bearing weight on the left leg.
• Limited range of motion in the hip.

Diagnosis

• Physical examination to assess swelling, tenderness, and mobility.
• Imaging, typically X-rays, are used to confirm the fracture and assess the alignment of the growth plate.

Treatment Options

• Immobilization of the leg with a cast or brace to allow for proper healing.
• In severe cases, surgical intervention may be required to realign the growth plate.
• Pain management with medications like acetaminophen or ibuprofen.

Prognosis and Follow-Up

• Positive prognosis with proper treatment, most children experience full recovery and return to normal activities.
• Follow-up appointments are crucial for monitoring the healing process and assessing the growth plate's development.

Complications

• If not treated correctly, complications could include growth disturbances or deformities in the affected limb.
• Risk of non-union or improper healing if the fracture is not adequately immobilized.

Lifestyle & Prevention

• Encourage safe play and use of protective gear during sports.
• Educate about proper technique and safety in physical activities to minimize risk of injury.

When to Seek Professional Help

• Persistent pain or inability to use the leg.
• Swelling, bruising, or significant changes in leg movement following an injury.

Additional Resources

• American Academy of Pediatrics
• National Institutes of Health (NIH)
• Local orthopedic or pediatric clinics

Tips for Medical Coders

• Ensure accurate coding by confirming the specific side (left femur) and type (Salter-Harris Type I) of the fracture.
• Verify that the encounter is coded as a "subsequent encounter with routine healing" as indicated by the "D" in S79.012D.
• Double-check for any documentation errors or missing information that could impact code accuracy.