S82.491M Other fracture of shaft of right fibula, subsequent encounter for open fracture type I or II with nonunion

Name of the Condition

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

Summary

This condition describes a fracture of the shaft (middle portion) of the right fibula, the smaller bone in the lower leg, during a subsequent encounter. The fracture is classified as an open type I or II, meaning the bone broke through the skin (type I: small wound; type II: larger, contaminated wound), and nonunion is present, indicating the fracture has not healed properly. The term "other" specifies the fracture type is distinct but not classified under narrower subcategories.

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. Nonunion can result from inadequate immobilization, poor blood supply, infection, or severe displacement.

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.
• Smoking or poor nutrition, which can impair healing.

Symptoms

• Persistent 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 (if open fracture).
• Possible deformity or instability of the leg structure.
• Lack of healing signs (e.g., no callus formation) over time.

Diagnosis

Diagnosis involves a physical examination by a healthcare professional to assess tenderness, swelling, deformity, and wound status. Imaging tests, such as X-rays or CT scans, are used to confirm the fracture, assess alignment, and evaluate for nonunion (e.g., visible gap between bone fragments or lack of healing progress). Blood tests may check for infection or nutritional deficiencies.

Treatment Options

Treatment focuses on promoting healing and addressing nonunion. Options may include surgical intervention (e.g., bone grafting, internal fixation) to stabilize the fracture, antibiotics for open fractures, and immobilization with a cast or brace. Physical therapy helps restore strength and mobility once healing progresses.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture, treatment adherence, and overall health. Nonunion may require extended recovery or additional procedures. Regular follow-up with imaging is necessary to monitor healing. Most patients regain function with proper care, though some may experience residual stiffness or weakness.

Complications

• Infection (especially with open fractures).
• Chronic pain or instability.
• Nerve or blood vessel damage.
• Delayed or failed healing (nonunion).
• Post-traumatic arthritis.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider.
• Maintain a balanced diet rich in calcium and vitamin D to support bone health.
• Use protective gear during sports or activities with fall risks.
• Follow post-treatment instructions carefully to aid healing.

When to Seek Professional Help

Seek immediate care if you experience severe pain, swelling, open wounds, or inability to bear weight. Contact a healthcare provider if symptoms worsen, or if you notice signs of infection (e.g., redness, pus, fever) or delayed healing.

Tips for Medical Coders

Document the encounter as a subsequent visit (not initial) and specify the open fracture type (I or II) and nonunion. Ensure clinical notes confirm the fracture’s status (e.g., imaging reports, wound assessment) to support coding accuracy. Code S82.491M is used when the patient is being seen for follow-up of an open fracture type I or II of the right fibula shaft with nonunion.