Name of the Condition

• Displaced Segmental Fracture of Shaft of Left Tibia, Initial Encounter for Closed Fracture
• Also known as: Tibial Fracture, Segmental Fracture of Left Tibia

Summary

• A displaced segmental fracture of the shaft of the left tibia is a break involving multiple segments of the bone, causing misalignment. It typically results from a traumatic injury.

Causes

• Commonly caused by high-energy trauma such as motor vehicle accidents, falls from significant height, or sports injuries.
• Can result from direct impact to the shin or excessive force applied to the leg.

Risk Factors

• Participation in high-impact sports or activities
• Inadequate protective gear during physical activities
• Osteoporosis or bone weakening conditions
• Previous fractures, which can predispose to further injuries

Symptoms

• Intense pain and swelling in the lower leg
• Visible deformity or irregularity in the shape of the shin
• Inability to bear weight on the affected leg
• Bruising and tenderness

Diagnosis

• Physical examination to assess swelling, deformity, and tenderness.
• Imaging tests such as X-rays to visualize the fracture and any displacement.
• CT scans may be used for further assessment if the fracture patterns are complex.

Treatment Options

• Closed reduction and immobilization: Aligning the bone fragments and stabilizing with a cast or brace.
• Surgical intervention: May involve internal fixation with plates, screws, or intramedullary nails to hold the bone segments in place.
• Physical therapy: Essential post-treatment for restoring mobility and strength.

Prognosis and Follow-Up

• With appropriate treatment, the prognosis is generally good, though healing can take several months.
• Regular follow-up appointments for X-rays and assessment to ensure proper healing.
• Physical therapy is crucial for full recovery of function and strength.

Complications

• Delayed union or nonunion, where the bone does not heal properly.
• Compartment syndrome, which is increased pressure within the muscles.
• Infection, particularly if surgery is required.
• Post-traumatic arthritis in the affected leg.

Lifestyle & Prevention

• Ensure adequate calcium and vitamin D for bone health.
• Use appropriate protective gear during sports or high-risk activities.
• Maintain a healthy weight to reduce stress on the bones.
• Engage in weight-bearing exercises to strengthen bones.

When to Seek Professional Help

• Immediate medical attention is required if there is intense pain, visible deformity, or inability to move or bear weight on the leg.
• Seek urgent care for signs of infection (fever, red or swollen leg).

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS)
• Orthoinfo (from AAOS)
• Your local orthopedic center or hospital

Tips for Medical Coders

• Ensure accurate coding by verifying the fracture type (displacement, segmental) and encounter stage (initial).
• Common errors include misclassifying the laterality or the encounter phase, so double-check documentation.
• Consider both fracture type and specifics of the encounter to accurately capture the complexity and required treatments.