S82.154R Nondisplaced fracture of right tibial tuberosity, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

Name of the Condition

• Nondisplaced fracture of right tibial tuberosity, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

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 classified as type IIIA, IIIB, or IIIC, indicating the skin over the fracture site was compromised and the wound is extensive. The fracture has malunion, meaning the bone has healed in a non-anatomic position, which may affect knee function. The tibial tuberosity is critical for knee extension, and even nondisplaced fractures can impact mobility.

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. Malunion may result from inadequate initial treatment, delayed healing, or excessive movement during recovery.

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
• Delayed or inadequate initial fracture management

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
• Altered knee mechanics due to malunion

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 malunion. CT or MRI may be employed to assess soft tissue damage or bone healing. The classification of the open fracture (IIIA, IIIB, or IIIC) is determined by the extent of soft tissue injury, contamination, and vascular compromise. Documentation of the fracture type and malunion is critical for accurate coding.

Treatment Options

Treatment focuses on managing the open fracture and addressing malunion. This may include surgical intervention to clean the wound, stabilize the fracture, or correct malunion. Antibiotics are often prescribed to prevent infection. Physical therapy is recommended to restore knee function and strength. Pain management and wound care are also essential components of treatment.

Prognosis and Follow-Up

Prognosis depends on the severity of the open fracture and the degree of malunion. With appropriate treatment, most patients can regain functional knee movement, though some may experience long-term limitations. Follow-up care includes regular imaging to monitor healing and physical therapy to improve mobility. Complications such as infection or persistent pain may require additional interventions.

Complications

• Infection at the fracture site
• Persistent pain or stiffness
• Limited knee extension or function
• Delayed or nonunion of the fracture
• Nerve or vascular damage from the initial injury

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider
• Use protective gear during sports or high-risk activities
• Maintain bone health through proper nutrition and exercise
• Follow post-treatment guidelines to support healing

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, swelling, or inability to bear weight. Contact a healthcare provider if you notice signs of infection, such as redness, warmth, or drainage from the wound, or if knee function does not improve with treatment.

Tips for Medical Coders

Document the fracture type (IIIA, IIIB, or IIIC) and the presence of malunion to accurately assign this code. Ensure subsequent encounter details are clearly recorded, including the nature of the open fracture and any complications. Verify that the fracture is nondisplaced and localized to the right tibial tuberosity.