S82.154E Nondisplaced fracture of right tibial tuberosity, subsequent encounter for open fracture type I or II with routine healing

Name of the Condition

• Nondisplaced fracture of right tibial tuberosity, subsequent encounter for open fracture type I or II with routine healing

Summary

A nondisplaced fracture of the right tibial tuberosity involves a break in the bony prominence on the anterior upper tibia where the patellar tendon attaches, with no misalignment of bone fragments. This is a subsequent encounter for an open fracture type I or II, indicating the skin over the fracture site was compromised but the wound is now healing routinely. The tibial tuberosity is critical for knee extension, and even nondisplaced fractures can impact function.

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 injury breaches the skin, exposing the fracture site.

Risk Factors

• Participation in high-impact sports (e.g., basketball, soccer)
• Adolescent growth spurts, especially in athletes
• Previous knee injuries or surgeries
• Activities involving sudden stops or jumps

Symptoms

• Localized pain and swelling over the tibial tuberosity
• Difficulty extending the knee or bearing weight
• Visible wound or laceration at the fracture site (for open fractures)
• Bruising or tenderness on palpation

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 used to assess soft tissue involvement or healing progress. Documentation should specify the fracture type (open I or II) and healing status.

Treatment Options

Treatment focuses on pain management, immobilization (e.g., brace or cast), and monitoring for infection in open fractures. Physical therapy may be initiated to restore range of motion and strength once healing permits. Routine follow-up ensures proper healing and addresses any complications.

Prognosis and Follow-Up

Prognosis is generally favorable with routine healing, especially for nondisplaced fractures. Follow-up appointments monitor healing progress, functional recovery, and wound care for open fractures. Most patients regain full knee function with appropriate treatment and rehabilitation.

Complications

• Infection (for open fractures)
• Delayed union or nonunion
• Persistent pain or stiffness
• Muscle weakness or atrophy

Lifestyle & Prevention

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

When to Seek Professional Help

Seek care if pain worsens, swelling increases, or signs of infection (e.g., redness, pus) appear. Immediate attention is needed for new trauma or loss of function.

Tips for Medical Coders

Document the fracture type (open I or II), healing status (routine), and encounter type (subsequent) clearly. Ensure clinical notes specify the right tibial tuberosity and confirm nondisplacement. Code S82.154E applies to subsequent encounters for open fractures with routine healing.