S82.151B Displaced fracture of right tibial tuberosity, initial encounter for open fracture type I or II

Name of the Condition

• Displaced fracture of right tibial tuberosity, initial encounter for open fracture type I or II

Summary

A displaced fracture of the right tibial tuberosity involves a break in the bony prominence on the anterior right tibia where the patellar tendon attaches. This specific ICD code refers to an initial encounter for an open fracture, where the bone pierces the skin or is otherwise exposed. Displacement can affect tendon function and knee stability.

Causes

Traumatic injury is the primary cause, such as direct impact to the knee, falls, or sudden forceful contraction of the quadriceps muscle. Sports-related incidents, particularly in adolescents, are common triggers. Open fractures may result from high-energy trauma that breaches the skin.

Risk Factors

• Participation in high-impact sports (e.g., basketball, soccer)
• Adolescent growth spurts with rapid bone growth
• Previous knee injuries or tendon abnormalities
• Activities involving sudden stops or jumps
• Open fractures may be more likely with high-impact trauma or penetrating injuries

Symptoms

• Localized pain and swelling over the tibial tuberosity
• Difficulty extending the knee or bearing weight
• Visible deformity or prominence at the fracture site
• Bruising or tenderness on palpation
• Open wound or visible bone fragments in the case of an open fracture

Diagnosis

Diagnosis involves a physical examination to assess pain, swelling, and functional limitations. Imaging studies, such as X-rays, are used to confirm the fracture and evaluate displacement. CT or MRI may be ordered for complex cases. The open fracture type (I or II) is determined by the size and contamination of the wound.

Treatment Options

• Immobilization with a brace or cast to stabilize the fracture
• Pain management with analgesics or anti-inflammatories
• Surgical intervention to realign and fixate the fracture if displaced
• Wound care for open fractures to prevent infection
• Physical therapy to restore mobility and strength

Prognosis and Follow-Up

Prognosis depends on fracture severity, displacement, and treatment. Most patients recover with proper immobilization and rehabilitation. Follow-up imaging may be needed to assess healing. Open fractures require close monitoring for infection.

Complications

• Nonunion or malunion of the fracture
• Infection, particularly with open fractures
• Chronic pain or instability
• Limited knee range of motion
• Potential for arthritis in the long term

Lifestyle & Prevention

• Use protective gear during high-impact sports
• Strengthen quadriceps and surrounding muscles
• Avoid sudden, forceful knee movements
• Maintain bone health through proper nutrition and exercise

When to Seek Professional Help

Seek immediate medical attention for severe pain, inability to bear weight, visible deformity, or open wounds. Prompt evaluation is critical for open fractures to reduce infection risk.

Tips for Medical Coders

This code specifies a displaced fracture of the right tibial tuberosity with an initial encounter for an open fracture type I or II. Document the fracture location (right), displacement, and open fracture type clearly. Ensure the encounter is noted as initial and the fracture type is accurately classified.