S82.152F Displaced fracture of left tibial tuberosity, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

Name of the Condition

• Displaced fracture of left tibial tuberosity, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

Summary

A displaced fracture of the left tibial tuberosity involves a break in the bony prominence on the anterior upper tibia where the patellar tendon attaches. Displacement means the bone fragments are misaligned, which may affect knee function. This code refers to a subsequent encounter for an open fracture (type IIIA, IIIB, or IIIC) with routine healing, indicating the fracture has progressed to a healing phase after initial treatment. Open fractures involve the bone piercing the skin, increasing infection risk, while routine healing suggests the fracture is progressing without complications.

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, motor vehicle accidents, or other high-impact events can lead to this fracture. Open fractures occur when the broken bone penetrates the skin, and subsequent encounters reflect ongoing management of the healing process.

Risk Factors

• Participation in activities with rapid knee extension or jumping (e.g., basketball, soccer)
• Adolescent growth spurts, especially in athletes
• Previous knee injuries or surgeries
• Osteoporosis or bone-weakening conditions
• High-impact trauma, such as falls or direct blows to the knee

Symptoms

• Persistent pain and swelling over the tibial tuberosity, though may be reduced compared to initial injury
• Limited ability to fully extend the knee or bear weight, depending on healing progress
• Possible residual deformity or abnormal positioning of the knee
• Bruising or discoloration in the affected area, with potential for skin changes from prior open fracture

Diagnosis

Diagnosis involves a physical examination to assess pain, swelling, and deformity. Imaging studies, such as X-rays, are used to confirm the fracture and evaluate displacement. Additional tests like MRI may be ordered to assess soft tissue healing or detect complications. Documentation should reflect the fracture type (IIIA, IIIB, or IIIC) and routine healing status.

Treatment Options

Treatment focuses on managing healing and restoring function. This may include immobilization with a brace or cast, physical therapy to improve range of motion and strength, and monitoring for infection or other complications. Surgical intervention may be considered if alignment issues persist. Pain management and wound care (if applicable) are also part of the care plan.

Prognosis and Follow-Up

Prognosis is generally favorable with routine healing, though recovery time varies. Follow-up appointments are essential to monitor healing progress, adjust treatment, and address any functional limitations. Most patients regain knee function, but residual stiffness or weakness may occur. Long-term follow-up may be needed for athletes or those with complex injuries.

Complications

• Infection, particularly if the fracture was open
• Nonunion or delayed healing
• Persistent pain or stiffness
• Arthritis or joint damage over time
• Nerve or vascular injury (rare)

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider
• Use proper protective gear during sports
• Maintain bone health through diet and exercise
• Follow rehabilitation guidelines to restore strength and mobility
• Seek prompt care for knee injuries to prevent complications

When to Seek Professional Help

• Increasing pain, swelling, or redness
• Signs of infection (e.g., fever, pus)
• Inability to bear weight or extend the knee
• Numbness, tingling, or changes in skin color
• Concerns about healing progress or functional limitations

Tips for Medical Coders

This code requires documentation of the fracture type (IIIA, IIIB, or IIIC) and confirmation of routine healing. Ensure the encounter is classified as "subsequent" and that the fracture is open with routine healing. Documentation should specify the left tibial tuberosity and displacement. Avoid using this code for initial encounters or closed fractures.