S82.155K Nondisplaced fracture of left tibial tuberosity, subsequent encounter for closed fracture with nonunion

Name of the Condition

• Nondisplaced fracture of left tibial tuberosity, subsequent encounter for closed fracture with nonunion

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 aligned. This is a subsequent encounter for a closed fracture that has failed to heal (nonunion). The injury typically results from trauma or excessive stress on the knee, often in active individuals, and requires ongoing management due to the nonunion status.

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. Nonunion may develop due to inadequate immobilization, poor blood supply, or persistent stress on 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
• Delayed or inadequate initial treatment

Symptoms

• Persistent localized pain and swelling over the tibial tuberosity
• Difficulty extending the knee or bearing weight
• Bruising or tenderness on palpation
• Minimal visible deformity due to nondisplacement
• Possible instability or weakness in the knee

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 alignment. CT or MRI may be ordered to assess bone healing and identify nonunion. Clinical history of prior fracture and lack of progression in healing are key considerations.

Treatment Options

• Immobilization with a brace or cast to reduce stress on the fracture site
• Physical therapy to maintain mobility and strengthen surrounding muscles
• Surgical intervention (e.g., bone grafting, internal fixation) if nonunion persists
• Pain management with medications or other modalities
• Monitoring for signs of infection or further complications

Prognosis and Follow-Up

Prognosis depends on the success of treatment and the body's ability to heal the nonunion. Follow-up imaging and clinical assessments are necessary to monitor healing progress. Long-term outcomes may include residual pain or functional limitations if healing is incomplete. Regular follow-up with an orthopedic specialist is recommended.

Complications

• Persistent nonunion requiring additional intervention
• Chronic pain or instability in the knee
• Limited range of motion or difficulty bearing weight
• Risk of infection (if surgical intervention is needed)
• Potential for future fractures due to weakened bone

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider
• Use proper protective equipment during sports or physical activities
• Maintain a healthy diet rich in calcium and vitamin D to support bone health
• Gradually return to activity under medical guidance to prevent re-injury
• Engage in low-impact exercises (e.g., swimming, cycling) to maintain fitness

When to Seek Professional Help

Seek immediate medical attention if you experience:

• Severe or worsening pain
• Increased swelling or bruising
• Inability to bear weight on the affected leg
• Signs of infection (e.g., fever, redness, drainage)
• Sudden loss of knee function or instability

Tips for Medical Coders

Document the subsequent encounter for a closed fracture with nonunion clearly, including details of the fracture's status and any treatments provided. Ensure the code S82.155K is used when the fracture is nondisplaced, closed, and has failed to heal, with appropriate clinical documentation supporting the nonunion diagnosis. Note the left-sided nature of the injury and the encounter type (subsequent) in the record.