S82.156M Nondisplaced fracture of unspecified tibial tuberosity, subsequent encounter for open fracture type I or II with nonunion

Name of the Condition

• Nondisplaced fracture of unspecified tibial tuberosity, subsequent encounter for open fracture type I or II with nonunion

Summary

A nondisplaced fracture of the tibial tuberosity involves a break in the bony prominence on the anterior 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 (skin breached but wound limited) and is associated with nonunion, meaning the fracture has failed to heal properly. The tibial tuberosity is critical for knee extension, and nonunion may lead to persistent pain or functional impairment despite the lack of displacement.

Causes

Traumatic injury is the primary cause, such as direct impact to the knee, falls, or sudden forceful contraction of the quadriceps muscle. Open fractures may result from high-energy trauma, where the force of the injury breaks the skin and exposes the fracture site. Nonunion can develop due to inadequate immobilization, poor blood supply, infection, or excessive movement at the fracture site during healing.

Risk Factors

• Participation in high-impact sports (e.g., basketball, soccer)
• Adolescent growth spurts with rapid bone growth
• Previous knee injuries or surgeries
• Osteoporosis or bone-weakening conditions
• Inadequate fracture immobilization or noncompliance with treatment
• Infection at the fracture site

Symptoms

• Persistent localized pain and swelling over the tibial tuberosity
• Difficulty extending the knee or bearing weight
• Bruising or tenderness on palpation
• Possible visible wound or scar from the open fracture
• Mild functional limitation without visible deformity

Diagnosis

Diagnosis involves a physical examination to assess pain, swelling, and wound status, followed by imaging studies such as X-rays or CT scans to confirm the fracture and evaluate for nonunion. The open fracture type (I or II) is determined by the size and contamination of the wound. Additional tests may include blood work to rule out infection or assess healing.

Treatment Options

Treatment focuses on promoting fracture union and managing the open wound. Options may include surgical intervention (e.g., internal fixation, bone grafting) to stabilize the fracture and address nonunion, along with wound care to prevent infection. Conservative management, such as immobilization with a cast or brace, may be used if surgery is not required. Physical therapy is often recommended to restore function once healing progresses.

Prognosis and Follow-Up

Prognosis depends on the success of treatment and the extent of nonunion. With appropriate intervention, most patients can achieve fracture union and return to normal activities, though recovery may be prolonged. Follow-up appointments are necessary to monitor healing, assess for complications, and adjust treatment as needed. Long-term monitoring may be required to ensure the fracture site remains stable.

Complications

• Persistent nonunion requiring additional surgery
• Infection at the fracture or wound site
• Chronic pain or functional impairment
• Limited knee range of motion
• Delayed union or malunion

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider
• Follow prescribed immobilization and weight-bearing restrictions
• Maintain good nutrition to support bone healing
• Practice proper wound care if an open fracture is present
• Engage in gradual physical therapy to restore strength and mobility

When to Seek Professional Help

Seek immediate medical attention if you experience:

• Severe or worsening pain
• Increased swelling, redness, or drainage from the wound
• Inability to bear weight or extend the knee
• Signs of infection (e.g., fever, pus)
• Sudden changes in fracture site appearance or function

Tips for Medical Coders

Document the fracture type (open I or II), the presence of nonunion, and the encounter type (subsequent) clearly in the medical record. Ensure the open fracture classification is supported by wound description and imaging. Nonunion should be confirmed through clinical assessment or imaging to justify the code.