S82.155P Nondisplaced fracture of left tibial tuberosity, subsequent encounter for closed fracture with malunion

Name of the Condition

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

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 code specifies a subsequent encounter for a closed fracture that has healed with malunion, meaning the fracture site has united but in a non-anatomical position. The injury typically results from trauma or excessive stress on the knee, often in active individuals, and malunion may affect knee function or alignment.

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. Malunion occurs when the fracture heals in a misaligned position, which may result from inadequate immobilization, poor blood supply, or excessive movement during healing.

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
• Inadequate fracture immobilization or premature weight-bearing

Symptoms

• Localized pain and swelling over the tibial tuberosity
• Difficulty extending the knee or bearing weight
• Bruising or tenderness on palpation
• Altered knee alignment or function due to malunion
• Possible joint stiffness or reduced range of motion

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 malunion severity and its impact on knee mechanics. Clinical correlation with prior fracture history is essential.

Treatment Options

Treatment focuses on managing symptoms and addressing functional impairment from malunion. Options may include physical therapy to improve strength and mobility, orthotic devices for support, or surgical intervention (e.g., osteotomy) for significant malalignment. Pain management and activity modification are often part of the plan.

Prognosis and Follow-Up

Prognosis depends on the extent of malunion and its effect on knee function. Most patients recover with conservative management, but severe malunion may lead to chronic pain or instability. Regular follow-up with imaging and functional assessments ensures appropriate intervention if symptoms persist or worsen.

Complications

• Chronic knee pain or instability
• Reduced range of motion
• Increased risk of future knee injuries
• Potential need for surgical correction
• Long-term functional limitations

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a provider
• Use proper protective gear during sports
• Maintain strong quadriceps and hamstring muscles
• Gradually resume activity with guidance from a physical therapist
• Monitor for changes in knee function or pain

When to Seek Professional Help

Seek care if you experience worsening pain, swelling, or difficulty bearing weight, or if knee function declines. Persistent instability, locking, or inability to extend the knee fully requires prompt evaluation.

Tips for Medical Coders

This code is for a subsequent encounter of a closed fracture with malunion. Document the fracture's healing status, malunion confirmation, and any functional impact. Ensure the encounter is subsequent (not initial) and the fracture remains closed. Include details on treatment provided and follow-up care to support coding accuracy.