S82.464E Nondisplaced segmental fracture of shaft of right fibula, subsequent encounter for open fracture type I or II with routine healing

Name of the Condition

• Nondisplaced segmental fracture of shaft of right fibula, subsequent encounter for open fracture type I or II with routine healing
• ICD-10 Code: S82.464E

Summary

A nondisplaced segmental fracture of the shaft of the right fibula is a break in the long, thin bone of the lower leg involving two separate fracture sites along the same bone segment, with the fragments remaining in alignment. This injury is classified as an open fracture type I or II, meaning the overlying skin is compromised but the wound is typically small and clean. The "subsequent encounter" designation indicates this is a follow-up visit for treatment, and "routine healing" confirms the fracture is progressing without complications.

Causes

Most commonly caused by high-energy trauma, such as motor vehicle accidents, falls from significant height, or direct impact to the leg. Twisting injuries or severe rotational forces can also lead to this type of fracture. Open fractures may result from the trauma piercing the skin or from a pre-existing wound becoming contaminated.

Risk Factors

• Participation in high-impact sports or activities with risk of falls.
• Osteoporosis or reduced bone density, which increases fragility.
• Advanced age, which may weaken bone strength.
• Previous leg injuries or surgeries that compromise bone integrity.
• Exposure to environments with increased risk of trauma (e.g., construction sites).

Symptoms

• Intense 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.
• Numbness or tingling if nerve involvement occurs.

Diagnosis

Diagnosis involves a physical examination by a healthcare professional to assess tenderness, swelling, and range of motion. Imaging studies, such as X-rays or CT scans, are typically used to confirm the fracture type and alignment. The open fracture classification is determined by evaluating the size and cleanliness of the skin wound. Follow-up imaging may be performed to monitor healing progress.

Treatment Options

Treatment focuses on stabilizing the fracture and promoting healing. This may include immobilization with a cast or brace, pain management, and wound care for the open fracture. Physical therapy is often recommended to restore strength and mobility once healing allows. Surgical intervention is rarely needed for nondisplaced fractures but may be considered if complications arise.

Prognosis and Follow-Up

With proper treatment, most nondisplaced segmental fractures of the fibula heal well. Routine healing indicates the fracture is progressing as expected, and follow-up visits are scheduled to monitor recovery. Full weight-bearing and return to normal activities typically occur within 6–8 weeks, depending on the individual's healing rate.

Complications

• Infection at the site of the open wound.
• Delayed healing or nonunion of the fracture.
• Nerve or blood vessel damage.
• Chronic pain or instability in the leg.
• Post-traumatic arthritis in the ankle or knee.

Lifestyle & Prevention

• Use protective gear during high-risk activities (e.g., helmets, padding).
• Maintain bone health through a balanced diet rich in calcium and vitamin D.
• Avoid activities that increase fall risk, especially in older adults.
• Strengthen leg muscles to improve stability and reduce injury likelihood.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, swelling, or deformity after an injury. Contact your healthcare provider if you notice signs of infection (e.g., redness, pus, fever) or if pain worsens despite treatment. Follow up as scheduled to ensure proper healing.

Tips for Medical Coders

Document the fracture type (open I or II), the encounter stage (subsequent), and the healing status (routine) to accurately assign S82.464E. Ensure clinical notes specify the fracture's alignment (nondisplaced) and segmental nature, as well as the absence of complications. Verify that the right fibula is clearly identified in the record.