S90.11 Contusion of great toe without damage to nail

Name of the Condition

• Contusion of great toe without damage to nail

Summary

A contusion of the great toe is a bruise resulting from blunt force trauma that damages underlying soft tissues without breaking the skin or affecting the nail. It typically causes localized pain, swelling, and discoloration in the toe area.

Causes

Direct impact or trauma to the great toe, such as stubbing it against a hard object or dropping a heavy item on the toe. Sports injuries or accidents involving the foot may also lead to this condition.

Risk Factors

• Participation in activities with a high risk of toe trauma, such as running or contact sports.
• Wearing open-toed or poorly fitting footwear that exposes the toe to injury.
• Occupations involving physical labor or environments where foot injuries are more likely.

Symptoms

• Pain and tenderness around the affected great toe.
• Localized swelling and discoloration (bruising) of the skin.
• Possible difficulty walking or applying pressure on the toe.

Diagnosis

Physical examination by a healthcare provider to assess tenderness, swelling, and discoloration. A review of the patient’s history to determine the mechanism of injury. Imaging (e.g., X-rays) may be used to rule out fractures or other injuries.

Treatment Options

• Resting the affected toe to avoid further injury.
• Applying ice to reduce pain and swelling.
• Elevating the foot to minimize swelling.
• Pain relief medications if needed.

Prognosis and Follow-Up

Most contusions heal within 1–2 weeks with proper care. Follow-up may be recommended if symptoms worsen or persist, to ensure no underlying issues are present.

Complications

• Persistent pain or swelling beyond the expected healing time.
• Infection if the skin is broken (though this code specifies no nail damage, secondary injury could occur).
• Chronic discomfort or limited mobility if the injury is severe or improperly managed.

Lifestyle & Prevention

• Wear protective footwear during activities with a high risk of toe injury.
• Avoid walking barefoot in environments where objects could strike the toe.
• Use caution when moving heavy objects to prevent accidental drops on the foot.

When to Seek Professional Help

Seek medical attention if pain is severe, swelling worsens, or there is difficulty bearing weight. Also, consult a provider if discoloration spreads or signs of infection (e.g., redness, pus) develop.

Tips for Medical Coders

This code (S90.11) is specific to a contusion of the great toe without nail damage. Ensure documentation clearly indicates the absence of nail injury and confirms the great toe as the affected site. Use this code for encounters where the primary issue is a bruise of the great toe without associated nail trauma.