S82.264N Nondisplaced segmental fracture of shaft of right tibia, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

Name of the Condition

• Nondisplaced segmental fracture of shaft of right tibia, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

Summary

A nondisplaced segmental fracture of the shaft of the right tibia is a fracture involving two separate breaks in the main portion of the tibia (shinbone), with the bone fragments remaining in their normal anatomical alignment. This injury is classified as an open fracture type IIIA, IIIB, or IIIC, indicating significant soft tissue damage, and is associated with nonunion, meaning the bone has failed to heal properly. The "subsequent encounter" designation indicates this is a follow-up visit for the fracture.

Causes

Nondisplaced segmental fractures of the tibial shaft commonly occur due to high-energy trauma, such as motor vehicle accidents, falls from height, or direct impact injuries. Open fractures result when the force of the injury causes the bone to pierce the skin, creating an external wound. Nonunion may develop due to inadequate immobilization, poor blood supply, infection, or other factors that impede healing.

Risk Factors

• Participation in high-impact sports or activities
• Osteoporosis or other bone-weakening conditions
• Previous lower leg injuries
• Age-related bone density loss
• Lack of protective gear during physical activities
• Smoking or poor nutrition affecting bone healing

Symptoms

• Persistent 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 at the fracture site
• Open wound at the injury site (for type IIIA, IIIB, or IIIC open fractures)
• Possible numbness or tingling in the foot (if nerve involvement)
• Signs of nonunion, such as persistent pain or lack of healing on imaging

Diagnosis

Diagnosis involves a physical examination to assess pain, swelling, and deformity, along with imaging studies such as X-rays, CT scans, or MRIs to confirm the fracture pattern, assess soft tissue damage, and evaluate for nonunion. Laboratory tests may be performed to check for infection or nutritional deficiencies affecting healing.

Treatment Options

Treatment focuses on addressing the nonunion and open fracture. Options may include surgical intervention to stabilize the fracture (e.g., internal or external fixation), bone grafting to promote healing, and management of soft tissue damage. Antibiotics may be used to treat or prevent infection, and physical therapy is often recommended to restore function.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture, soft tissue damage, and response to treatment. Follow-up care is essential to monitor healing, address complications, and adjust treatment as needed. Regular imaging and clinical evaluations help assess progress and guide rehabilitation.

Complications

• Infection at the fracture site
• Delayed or failed healing (nonunion)
• Nerve or blood vessel damage
• Chronic pain or disability
• Malalignment of the bone
• Soft tissue necrosis or wound breakdown

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider
• Follow prescribed weight-bearing restrictions
• Maintain a balanced diet rich in calcium and vitamin D to support bone health
• Quit smoking, as it impairs healing
• Use protective gear during sports or activities to reduce injury risk

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, swelling, or deformity in the lower leg, or if you notice an open wound at the injury site. Contact your healthcare provider if you have persistent pain, signs of infection (e.g., redness, warmth, fever), or if the fracture does not appear to be healing as expected.

Tips for Medical Coders

Document the fracture type (IIIA, IIIB, or IIIC) and the presence of nonunion clearly in the medical record. Ensure the encounter is coded as "subsequent" to reflect follow-up care. Include details about the fracture's alignment, soft tissue involvement, and any surgical or therapeutic interventions performed.