S92.335B Nondisplaced fracture of third metatarsal bone, left foot, initial encounter for open fracture

Name of the Condition

• Nondisplaced fracture of third metatarsal bone, left foot, initial encounter for open fracture.

Summary

A nondisplaced fracture of the third metatarsal bone in the left foot is a break in the long bone connecting the ankle to the toes, where the bone fragments remain in their normal alignment. This injury is classified as an open fracture, meaning the skin is broken, and it is the initial encounter for treatment. Open fractures require prompt medical attention to reduce infection risk and ensure proper healing.

Causes

Direct trauma to the left foot, such as a crush injury, fall, or penetrating wound, is the primary cause. Open fractures may result from high-energy impacts or injuries that break the skin and underlying bone simultaneously.

Risk Factors

• Participation in activities with a high risk of foot trauma (e.g., contact sports, construction work)
• Wearing inadequate or non-protective footwear
• Conditions that impair bone strength, such as osteoporosis or diabetes
• Advanced age, which may reduce bone density and increase fall risk
• Previous foot injuries or surgeries

Symptoms

• Severe pain, swelling, and tenderness in the midfoot area of the left foot
• Visible wound or break in the skin over the fracture site
• Difficulty bearing weight or walking on the affected foot
• Possible bleeding or drainage from the open wound
• Bruising or discoloration around the injury

Diagnosis

A healthcare provider will conduct a physical examination to assess the wound, pain, and range of motion. Imaging tests, such as X-rays, are used to confirm the fracture and verify that it is nondisplaced. The open nature of the fracture is documented to guide treatment.

Treatment Options

• Immediate wound care to clean and dress the open fracture to prevent infection
• Antibiotics to reduce infection risk
• Immobilization with a cast, splint, or brace to stabilize the bone
• Pain management with medications as needed
• Surgical intervention may be required if the wound is extensive or if there is significant contamination

Prognosis and Follow-Up

With proper treatment, most nondisplaced open fractures heal within 6–8 weeks. Follow-up appointments are necessary to monitor healing, remove sutures or dressings, and adjust immobilization. Physical therapy may be recommended to restore strength and mobility once healing is advanced.

Complications

• Infection at the wound site
• Delayed healing or nonunion of the fracture
• Chronic pain or stiffness in the foot
• Nerve or tissue damage from the initial injury
• Risk of future fractures due to weakened bone

Lifestyle & Prevention

• Wear protective footwear during high-risk activities
• Maintain bone health through a balanced diet and regular exercise
• Address underlying conditions that weaken bones, such as osteoporosis
• Practice fall prevention strategies, especially for older adults
• Seek prompt treatment for foot injuries to avoid complications

When to Seek Professional Help

• If the open wound shows signs of infection (e.g., increased redness, pus, fever)
• If pain worsens or does not improve with treatment
• If there is difficulty bearing weight or walking
• If there is numbness, tingling, or loss of circulation in the foot
• If the wound does not heal or shows signs of reopening

Tips for Medical Coders

Document the nondisplaced nature of the fracture, the left foot involvement, and the open fracture status clearly. Note the initial encounter for treatment, as this affects code assignment. Ensure wound characteristics and any associated injuries are recorded to support accurate coding.