Name of the Condition

• Unspecified fracture of shaft of left fibula, initial encounter for closed fracture
• ICD-10 Code: S82.402A

Summary

• This condition refers to a fracture (break) of the middle portion of the fibula, the smaller of the two bones in the lower leg, on the left side. In this context, it is a closed fracture, meaning the bone is broken but the skin is not pierced, and it is the patient's first medical treatment encounter for this injury.

Causes

• Most commonly caused by direct trauma or impact to the outside of the leg, such as from falls, sports injuries, or accidents.

Risk Factors

• Participation in contact sports.
• High-risk occupations or activities that increase the likelihood of falls or impacts.
• Osteoporosis or reduced bone density, which increases fragility.
• Advanced age, which may weaken bone strength.

Symptoms

• Pain and swelling in the lower leg.
• Difficulty bearing weight on the leg.
• Bruising or tenderness around the injured area.
• Possible deformity or instability of the leg structure.

Diagnosis

• Physical examination by a healthcare professional.
• Imaging tests such as X-rays, to determine the exact location and extent of the fracture.

Treatment Options

• Immobilization of the leg using a splint or cast to allow the bone to heal properly.
• Pain management with medications such as analgesics or anti-inflammatories.
• In some cases, surgical intervention may be required to align and stabilize the fracture.
• Physical therapy to restore strength and mobility post-healing.

Prognosis and Follow-Up

• With appropriate treatment, most fibula fractures heal well within 6 to 12 weeks.
• Regular follow-up appointments are crucial to monitor healing and ensure proper bone alignment.
• Rehabilitation exercises may be necessary to fully regain strength and function.

Complications

• Potential for improper bone healing, leading to misalignment or chronic pain.
• Risk of nerve or blood vessel damage in severe cases.
• Compartment syndrome, a rare but serious condition, may develop, necessitating immediate treatment.

Lifestyle & Prevention

• Engage in weight-bearing exercises to strengthen bones.
• Use protective gear during high-risk activities or sports.
• Maintain a diet rich in calcium and vitamin D to support bone health.
• Avoid smoking and excessive alcohol consumption, which can weaken bones.

When to Seek Professional Help

• If there is severe pain, swelling, or inability to use the leg.
• If there is numbness, tingling, or loss of circulation to the affected area.
• If signs of infection occur, such as redness, warmth, or fever.

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS)
• OrthoInfo by the AAOS (https://orthoinfo.aaos.org/)
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Tips for Medical Coders

• Ensure ICD-10 code S82.402A is used specifically for an unspecified fracture of the shaft of the left fibula during the initial encounter for a closed fracture.
• Avoid confusion with similar codes that specify different locations, open fractures, or follow-up encounters.
• Double-check that documentation clearly states the left side and closed nature of the fracture to accurately assign the code.