S82.402K Unspecified fracture of shaft of left fibula, subsequent encounter for closed fracture with nonunion

Name of the Condition

• Unspecified fracture of shaft of left fibula, subsequent encounter for closed fracture with nonunion
• ICD-10 Code: S82.402K

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. It is a closed fracture, meaning the bone is broken but the skin is not pierced, and the fracture has failed to heal (nonunion) during a subsequent medical 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. Nonunion may result from inadequate immobilization, poor blood supply to the bone, infection, or severe initial injury.

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.
• Smoking or poor nutrition, which can impair bone healing.

Symptoms

• Persistent 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.
• No visible improvement in symptoms over time, despite prior treatment.

Diagnosis

Physical examination by a healthcare professional, followed by imaging tests such as X-rays, to determine the exact location and extent of the fracture. Additional assessments may evaluate bone healing progress and identify nonunion.

Treatment Options

• Surgical intervention, such as bone grafting or internal fixation, to promote healing.
• Immobilization of the leg using a splint or cast to stabilize the fracture.
• Pain management with medications such as analgesics.
• Physical therapy to restore strength and mobility.

Prognosis and Follow-Up

Prognosis depends on the severity of the nonunion and the effectiveness of treatment. Regular follow-up with imaging is typically required to monitor healing. Recovery may be prolonged, and some patients may experience long-term functional limitations.

Complications

• Chronic pain or discomfort.
• Persistent instability of the leg.
• Increased risk of future fractures.
• Potential need for additional surgeries.

Lifestyle & Prevention

• Avoid high-impact activities until fully healed.
• Maintain a balanced diet rich in calcium and vitamin D to support bone health.
• Use protective gear during sports or high-risk activities.
• Quit smoking, as it can hinder bone healing.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, swelling, or inability to bear weight, or if symptoms worsen despite treatment.

Tips for Medical Coders

Document the encounter as a subsequent visit for a closed fracture with nonunion. Ensure clinical notes specify the fracture location (shaft of left fibula), the absence of skin penetration, and the failure of the fracture to heal. Code S82.402K is appropriate when the encounter is for treatment of the nonunion during the healing phase.