S82.155M Nondisplaced fracture of left tibial tuberosity, subsequent encounter for open fracture type I or II with nonunion

Name of the Condition

• Nondisplaced fracture of left tibial tuberosity, subsequent encounter for open fracture type I or II 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 an open fracture type I or II (skin breach but limited wound) that has developed nonunion, meaning the fracture has not healed properly. The tibial tuberosity is critical for knee extension, and nonunion can impact function. Open fractures require careful management to prevent infection, and nonunion may necessitate additional interventions.

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. Nonunion may result from inadequate initial treatment, poor blood supply, or excessive motion at 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
• Open wounds near the tibial tuberosity (increasing infection risk)
• Factors contributing to nonunion (e.g., poor nutrition, smoking, certain medications)

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 signs of nonunion (e.g., persistent pain beyond expected healing time)
• Open wound (if present) with risk of infection

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, evaluate alignment, and assess for nonunion (e.g., visible fracture line, lack of callus formation). CT or MRI may be ordered to evaluate bone healing and soft tissue involvement. Laboratory tests may be performed to check for infection if the open wound is present.

Treatment Options

Treatment focuses on promoting fracture healing and managing the open wound. Options may include immobilization (e.g., cast or brace) to stabilize the fracture, surgical intervention (e.g., internal fixation, bone grafting) for nonunion, and wound care to prevent infection. Physical therapy may be recommended to restore knee function once healing progresses. Antibiotics may be prescribed if infection is suspected or present.

Prognosis and Follow-Up

Prognosis depends on the success of healing and management of nonunion. With appropriate treatment, many patients recover function, but nonunion may require additional interventions. Follow-up appointments are necessary to monitor healing (via imaging) and adjust treatment as needed. Long-term outcomes may include persistent pain or functional limitations if nonunion is not resolved.

Complications

• Nonunion (failure of the fracture to heal)
• Infection (due to open fracture)
• Chronic pain or instability
• Limited knee range of motion
• Need for additional surgery
• Potential for arthritis over time

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider
• Use proper protective equipment during sports
• Maintain a healthy diet to support bone healing
• Follow post-treatment instructions carefully
• Attend all follow-up appointments to monitor healing

When to Seek Professional Help

Seek immediate medical attention if there is severe pain, swelling, or inability to bear weight. Contact a healthcare provider if symptoms worsen, or if there are signs of infection (e.g., fever, increased redness, drainage from the wound). Follow up as scheduled to monitor healing and address concerns about nonunion.

Tips for Medical Coders

Document the encounter as a subsequent visit for an open fracture type I or II with nonunion. Include details about the fracture status (nondisplaced), the open wound classification, and evidence of nonunion (e.g., imaging findings, clinical assessment). Ensure documentation supports the need for ongoing care and any interventions related to nonunion or wound management.