S82.155B Nondisplaced fracture of left tibial tuberosity, initial encounter for open fracture type I or II

Name of the Condition

• Nondisplaced fracture of left tibial tuberosity, initial encounter for open fracture type I or II

Summary

A nondisplaced fracture of the left tibial tuberosity involves a break in the bony prominence on the anterior upper tibia where the patellar tendon attaches, with the bone fragments remaining in their normal alignment. This injury is classified as an open fracture type I or II, meaning the overlying skin is breached but the wound is limited. The tibial tuberosity is critical for knee extension, and even nondisplaced fractures can impact function. Open fractures require careful management to prevent infection.

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. The open nature of the fracture indicates the skin was penetrated, often by the fractured bone or external force.

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
• Open wounds near the tibial tuberosity (increasing infection risk)

Symptoms

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

Diagnosis

Diagnosis involves a physical examination to assess pain, swelling, and wound characteristics. Imaging studies, such as X-rays, are used to confirm the fracture and evaluate displacement. CT or MRI may be ordered to assess soft tissue damage or wound extent. The open nature of the fracture is documented to guide treatment.

Treatment Options

• Wound cleaning and debridement to reduce infection risk
• Immobilization with a brace or cast to stabilize the fracture
• Antibiotics to prevent or treat infection
• Pain management with analgesics
• Surgical intervention if the wound is extensive or unstable

Prognosis and Follow-Up

Prognosis is generally favorable with proper treatment, though open fractures carry a higher infection risk. Follow-up includes monitoring for wound healing and infection signs. Physical therapy may be recommended to restore knee function once the fracture stabilizes. Long-term outcomes depend on fracture severity and adherence to treatment.

Complications

• Infection at the wound site
• Delayed healing due to open fracture
• Persistent pain or functional limitations
• Rarely, malunion or nonunion of the fracture

Lifestyle & Prevention

• Use protective gear during high-impact sports
• Avoid sudden, forceful knee movements
• Maintain bone health through proper nutrition and exercise
• Seek prompt care for knee injuries to prevent complications

When to Seek Professional Help

• Severe pain or swelling unrelieved by rest
• Visible wound or laceration at the knee
• Inability to bear weight or extend the knee
• Signs of infection (e.g., redness, drainage, fever)

Tips for Medical Coders

Document the fracture as nondisplaced and specify the left tibial tuberosity. Note the open fracture type (I or II) and initial encounter status. Include details on wound characteristics and treatment to support code accuracy. Ensure alignment with clinical documentation for proper coding.