S92.355B Nondisplaced fracture of fifth metatarsal bone, left foot, initial encounter for open fracture

Name of the Condition

• Technical Term: Nondisplaced fracture of fifth metatarsal bone, left foot, initial encounter for open fracture
• Common Name: Open fracture of the left fifth metatarsal (nondisplaced)

Summary

A nondisplaced fracture of the fifth metatarsal bone in the left foot is a break in the outer long bone of the foot that remains in its normal alignment. This specific case is classified as an open fracture, meaning the bone has pierced the skin, and it is documented as the initial encounter for this injury. Open fractures require prompt medical attention to reduce infection risk and stabilize the bone.

Causes

Direct trauma to the foot, such as a severe fall, crush injury, or high-impact event, is the primary cause. Open fractures occur when the force of the injury is sufficient to break the skin and expose the fractured bone.

Risk Factors

• Participation in activities with high risk of foot trauma (e.g., contact sports, industrial work)
• Wearing inadequate protective footwear
• Conditions that weaken bones, such as osteoporosis
• Previous foot injuries or surgeries
• Advanced age, which may reduce bone density and balance

Symptoms

• Pain and tenderness on the outer edge of the left foot
• Visible wound or laceration over the fracture site
• Swelling, bruising, or bleeding at the injury
• Difficulty bearing weight on the left foot
• Possible exposure of bone through the skin

Diagnosis

A healthcare provider will perform 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 its alignment. The open nature of the fracture is documented based on clinical observation of the wound and bone exposure.

Treatment Options

• Immediate wound care to clean and dress the open fracture to prevent infection
• Immobilization using a cast, splint, or external fixator to stabilize the bone
• Antibiotics to reduce infection risk
• Surgical intervention if the fracture requires internal fixation or if the wound is extensive
• Pain management and monitoring for complications

Prognosis and Follow-Up

Most nondisplaced open fractures heal well with proper treatment, but the open nature increases infection risk. Follow-up appointments are necessary to monitor healing, assess for signs of infection, and adjust treatment as needed. Physical therapy may be recommended to restore strength and mobility after initial healing.

Complications

• Infection at the wound site
• Delayed healing due to the open nature of the fracture
• Potential for bone nonunion or malunion if not properly stabilized
• Nerve or tissue damage from the injury or treatment

Lifestyle & Prevention

• Wear appropriate protective footwear for high-risk activities
• Maintain bone health through a balanced diet and regular exercise
• Avoid activities that increase the risk of foot trauma when possible
• Seek prompt medical care for foot injuries to prevent complications

When to Seek Professional Help

• If the fracture is open (bone visible through the skin)
• Severe pain, swelling, or bleeding that does not improve
• Inability to bear weight on the foot
• Signs of infection, such as increased redness, pus, or fever

Tips for Medical Coders

Document the open nature of the fracture and the initial encounter status clearly. Ensure the left foot and nondisplaced alignment are specified. Code S92.355B is used for the initial encounter of an open, nondisplaced fracture of the left fifth metatarsal bone.