S82.454B Nondisplaced comminuted fracture of shaft of right fibula, initial encounter for open fracture type I or II

Name of the Condition

• Nondisplaced comminuted fracture of shaft of right fibula, initial encounter for open fracture type I or II
• ICD-10 Code: S82.454B

Summary

A nondisplaced comminuted fracture of the shaft of the right fibula is a break in the long, slender bone of the lower leg where the bone is shattered into multiple pieces but the fragments remain in their original alignment. This fracture is classified as an open fracture type I or II, meaning the skin is broken (type I) or there is a wound extending to the fracture site with minimal soft tissue damage (type II). The initial encounter indicates this is the first presentation for treatment.

Causes

This fracture typically results from direct trauma or high-impact force to the leg, such as falls, motor vehicle accidents, or sports injuries. The comminution (shattering into multiple pieces) occurs due to significant force, while the nondisplaced nature suggests the fragments did not shift out of position. Open fracture types I or II indicate the skin was breached during the injury.

Risk Factors

• Participation in high-impact or contact sports
• Osteoporosis or conditions that weaken bone density
• Advanced age, which may reduce bone strength
• Previous leg injuries or surgeries

Symptoms

• Pain and tenderness along the right fibula
• Swelling and bruising around the lower leg
• Difficulty bearing weight on the affected leg
• Possible open wound at the fracture site (for type I or II open fractures)

Diagnosis

Diagnosis involves a physical examination to assess tenderness, swelling, and any open wounds. Imaging tests, such as X-rays, are used to confirm the fracture, determine the number of bone fragments, and verify nondisplacement. The open fracture type is determined by evaluating the wound and soft tissue involvement.

Treatment Options

Treatment depends on the severity of the fracture and soft tissue damage. Options may include wound care for open fractures, immobilization with a cast or brace, and pain management. Surgical intervention is less common for nondisplaced fractures but may be considered if the open wound requires debridement or if there is significant soft tissue injury.

Prognosis and Follow-Up

Prognosis is generally favorable for nondisplaced fractures, especially with proper immobilization and wound care. Follow-up appointments are necessary to monitor healing, assess for infection (in open fractures), and determine when weight-bearing can resume. Physical therapy may be recommended to restore strength and mobility.

Complications

• Infection at the open wound site
• Delayed healing or nonunion
• Nerve or blood vessel damage
• Chronic pain or instability

Lifestyle & Prevention

• Use protective gear during high-impact activities
• Maintain bone health through diet and exercise
• Avoid falls by using assistive devices if needed
• Seek prompt treatment for leg injuries to prevent complications

When to Seek Professional Help

Seek immediate medical attention if there is severe pain, inability to bear weight, visible bone protrusion, or signs of infection (e.g., redness, pus, fever). Open fractures require urgent care to reduce infection risk.

Tips for Medical Coders

Document the fracture as nondisplaced and comminuted, specify the right fibula, and confirm the open fracture type (I or II) and initial encounter status. Ensure wound details and imaging results support the open fracture classification. Code S82.454B is specific to the right fibula; do not use for left-sided or unspecified fractures.