S82.454E Nondisplaced comminuted fracture of shaft of right fibula, subsequent encounter for open fracture type I or II with routine healing

Name of the Condition

• Nondisplaced comminuted fracture of shaft of right fibula, subsequent encounter for open fracture type I or II with routine healing
• ICD-10 Code: S82.454E

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 was breached during the injury (type I) or there is a wound extending to the fracture site with minimal soft tissue damage (type II). The "subsequent encounter" designation indicates this is a follow-up visit for treatment, and "routine healing" confirms the fracture is progressing normally without complications.

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 deformity or instability of the leg structure

Diagnosis

Diagnosis involves a physical examination to assess tenderness, swelling, and deformity. Imaging tests, such as X-rays, are typically used to confirm the fracture and determine the number of bone fragments, alignment, and healing progress. Documentation should specify the fracture type (open I or II) and healing status (routine) to support the code assignment.

Treatment Options

Treatment may include immobilization with a cast or brace to stabilize the fracture, pain management, and monitoring for healing. For open fractures, wound care is essential to prevent infection. Physical therapy may be recommended to restore strength and mobility once healing is underway.

Prognosis and Follow-Up

With routine healing, the prognosis is generally favorable. Follow-up visits are important to monitor progress and adjust treatment as needed. Most patients recover fully, though recovery time depends on the severity of the fracture and adherence to treatment plans.

Complications

Potential complications include infection (especially with open fractures), delayed healing, or nonunion. Nerve or blood vessel damage may occur, though less common with nondisplaced fractures. Routine healing reduces these risks, but ongoing monitoring is necessary.

Lifestyle & Prevention

Avoid high-impact activities until cleared by a healthcare provider. Strengthen leg muscles and maintain bone health through diet and exercise to reduce fracture risk. Use protective gear during sports or activities with fall risks.

When to Seek Professional Help

Seek immediate care for increased pain, swelling, redness, or drainage from the wound, as these may indicate infection. Contact a provider if weight-bearing becomes more difficult or if healing does not progress as expected.

Tips for Medical Coders

Document the fracture type (open I or II), healing status (routine), and encounter type (subsequent) to accurately assign S82.454E. Ensure clinical notes specify the right fibula and confirm the fracture is nondisplaced and comminuted. Routine healing should be clearly documented to support the code.