S90.112 Contusion of left great toe without damage to nail

Name of the Condition

• Contusion of left great toe without damage to nail

Summary

A contusion of the left 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 affected toe.

Causes

Direct impact or trauma to the left great toe, such as stubbing it against a hard object or dropping a heavy item on it. 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 toes to injury.
• Occupations involving physical labor or environments where foot injuries are more likely.

Symptoms

• Pain and tenderness around the affected left 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.
• Over-the-counter pain relievers (e.g., acetaminophen or ibuprofen) for discomfort.
• Wearing protective footwear to prevent additional trauma.

Prognosis and Follow-Up

Most contusions heal within 1–2 weeks with proper care. Follow-up may be recommended if symptoms worsen or persist, or if there is concern for underlying injury. Full recovery is expected with rest and conservative management.

Complications

• Prolonged pain or swelling if the injury is not properly managed.
• Infection risk if the skin is broken (though not typical for this code).
• Chronic discomfort or stiffness in rare cases.

Lifestyle & Prevention

• Wear closed-toe, well-fitting shoes during activities with a risk of toe injury.
• Use protective gear (e.g., toe guards) in sports.
• Maintain awareness of surroundings to avoid accidental impacts.
• Ensure footwear provides adequate support and cushioning.

When to Seek Professional Help

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

Tips for Medical Coders

Use this code for a contusion of the left great toe where the nail is intact and no skin breakage occurred. Document the mechanism of injury, affected side, and absence of nail damage to support accurate coding. Ensure the encounter type (e.g., initial, subsequent) aligns with the specific code version used.