S82.491E Other fracture of shaft of right fibula, subsequent encounter for open fracture type I or II with routine healing

Name of the Condition

• Other fracture of shaft of right fibula, subsequent encounter for open fracture type I or II with routine healing
• ICD-10 Code: S82.491E

Summary

This condition describes a fracture of the shaft (middle portion) of the right fibula, the smaller bone in the lower leg. It is a subsequent encounter for an open fracture type I or II with routine healing, meaning the patient is being seen again for this injury, the bone has broken through the skin (type I: small wound; type II: larger, contaminated wound), and healing is progressing normally without complications.

Causes

Most commonly caused by direct trauma or high-force impact to the right leg, such as from falls, sports injuries, or motor vehicle accidents. Twisting motions or repetitive stress may also lead to this type of fracture.

Risk Factors

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

Symptoms

• Pain and swelling in the lower right leg.
• Difficulty bearing weight on the affected leg.
• Bruising or tenderness around the injured area.
• Visible wound or open skin at the fracture site (may be healing).
• Possible deformity or instability of the leg structure.

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 and evaluate healing progress. Documentation of the open fracture type (I or II) and routine healing status is essential.

Treatment Options

Treatment may include immobilization with a cast or brace, pain management, and monitoring for infection if the fracture was open. Physical therapy is often recommended to restore strength and mobility as healing progresses. Follow-up care focuses on ensuring proper alignment and healing.

Prognosis and Follow-Up

With routine healing, most fractures of the fibula shaft heal well with appropriate care. Follow-up appointments are typically scheduled to monitor progress, adjust treatment, and assess for complications. Full recovery may take several weeks to months, depending on the severity of the injury.

Complications

Potential complications include infection (if the fracture was open), delayed healing, or malunion (improper healing). Nerve or blood vessel damage near the fracture site is also possible but less common.

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 there is increased pain, swelling, redness, or drainage from the wound, or if the leg becomes numb or discolored. These may indicate infection or poor healing.

Tips for Medical Coders

Document the fracture type (open I or II), subsequent encounter status, and routine healing to accurately assign S82.491E. Ensure clinical notes specify the fracture's location (right fibula shaft) and healing progress to support code selection.