S82.421F Displaced transverse fracture of shaft of right fibula, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

Name of the Condition

• Displaced transverse fracture of shaft of right fibula, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
• ICD-10 Code: S82.421F

Summary

This condition describes a displaced transverse fracture of the shaft of the right fibula, where the fracture line runs horizontally across the bone and the fragments are misaligned. The fracture is open (skin is pierced) and classified as type IIIA, IIIB, or IIIC, indicating significant soft tissue damage. This is a subsequent encounter, meaning the patient is receiving follow-up care for an established injury with routine healing progress.

Causes

Most commonly caused by high-force trauma to the lower leg, such as motor vehicle accidents, falls, or severe sports injuries. Open fractures may result from the bone fragment piercing the skin during the initial injury, leading to exposure of the fracture site.

Risk Factors

• Participation in high-impact or contact sports.
• Osteoporosis or reduced bone density, which increases fragility.
• Advanced age, which may weaken bone strength.
• Previous leg injuries or surgeries that compromise bone integrity.

Symptoms

• Persistent pain and swelling in the lower leg.
• Difficulty bearing weight on the affected leg.
• Bruising or tenderness around the injured area.
• Possible deformity or instability of the leg structure.
• Open wound at the fracture site (for open fractures).

Diagnosis

Diagnosis involves a physical examination by a healthcare professional to assess tenderness, swelling, and deformity. Imaging tests, such as X-rays, are typically used to confirm the fracture, evaluate alignment, and monitor healing progress. Clinical documentation should specify the fracture type (IIIA, IIIB, or IIIC) and the status of healing.

Treatment Options

Treatment may include immobilization with a cast or brace to support healing, pain management, and monitoring for infection or complications. Surgical intervention may be required for severe open fractures to clean the wound and stabilize the bone. Follow-up care focuses on ensuring proper healing and restoring function.

Prognosis and Follow-Up

With routine healing, most patients recover fully, though recovery time depends on fracture severity and treatment. Follow-up appointments are essential to monitor healing, adjust treatment, and address any complications. Physical therapy may be recommended to restore strength and mobility.

Complications

• Infection at the fracture site (especially with open fractures).
• Delayed healing or nonunion.
• Nerve or blood vessel damage.
• Chronic pain or instability.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider.
• Use protective gear during sports or activities with fall risks.
• Maintain bone health through a balanced diet and regular exercise.
• Follow post-injury care instructions to support healing.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, swelling, or an open wound at the fracture site, or if symptoms worsen during recovery. Contact your healthcare provider if you notice signs of infection, such as redness, pus, or fever.

Tips for Medical Coders

Document the fracture type (IIIA, IIIB, or IIIC) and confirm the encounter is subsequent with routine healing. Ensure clinical notes specify the fracture's alignment, openness, and healing status to support accurate coding.