S82.464N Nondisplaced segmental fracture of shaft of right fibula, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

Name of the Condition

• Nondisplaced segmental fracture of shaft of right fibula, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
• ICD-10 Code: S82.464N

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 IIIA, IIIB, or IIIC, indicating significant soft tissue damage and contamination. The "subsequent encounter" designation applies to follow-up care, and "nonunion" signifies that the fracture has failed to heal properly after an expected period.

Causes

Most commonly caused by high-energy trauma, such as motor vehicle accidents, falls from significant height, or direct impact to the leg. Open fractures may result from the trauma piercing the skin or from a pre-existing wound becoming contaminated. Nonunion can occur due to inadequate immobilization, poor blood supply, infection, or excessive movement at the fracture site.

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).
• Poor nutrition or smoking, which can impair bone healing.

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.
• Numbness or tingling if nerve involvement occurs.
• Signs of infection, such as redness, warmth, or drainage from the wound.

Diagnosis

Diagnosis involves a physical examination by a healthcare professional to assess tenderness, swelling, and stability. Imaging studies, such as X-rays or CT scans, are used to confirm the fracture pattern, assess for nonunion, and evaluate soft tissue damage. Laboratory tests may be ordered to check for infection or assess healing status.

Treatment Options

Treatment focuses on promoting fracture union and managing soft tissue damage. Options may include surgical intervention to stabilize the fracture, debride infected tissue, or apply bone grafts. Antibiotics are used to treat or prevent infection. Immobilization with a cast or brace may be necessary, along with physical therapy to restore function.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture, soft tissue damage, and response to treatment. Nonunion may require additional interventions, such as surgery or bone stimulation. Regular follow-up appointments are essential to monitor healing and adjust treatment plans as needed.

Complications

• Infection at the fracture site or wound.
• Delayed or failed healing (nonunion).
• Nerve or blood vessel damage.
• Chronic pain or instability.
• Limited mobility or functional impairment.

Lifestyle & Prevention

• Avoid high-risk activities or use protective gear when participating.
• Maintain a healthy diet rich in calcium and vitamin D to support bone health.
• Quit smoking, as it impairs bone healing.
• Follow post-treatment instructions carefully to promote proper healing.
• Attend all follow-up appointments to monitor progress.

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, such as redness, warmth, or drainage, or if pain persists despite treatment.

Tips for Medical Coders

Document the fracture type (IIIA, IIIB, or IIIC) and the presence of nonunion clearly. Specify the encounter as "subsequent" and note the right fibula involvement. Ensure documentation supports the open fracture classification and nonunion diagnosis to justify the code.