S92.355K Nondisplaced fracture of fifth metatarsal bone, left foot, subsequent encounter for fracture with nonunion

Name of the Condition

• Technical Term: Nondisplaced fracture of fifth metatarsal bone, left foot, subsequent encounter for fracture with nonunion
• Common Name: Nonunion of left fifth metatarsal (nondisplaced)

Summary

A nondisplaced fracture of the fifth metatarsal bone in the left foot with nonunion is a break in the outer long bone of the foot that remains in its normal alignment but has failed to heal properly. This is documented as a subsequent encounter, indicating ongoing care for the fracture. Nonunion occurs when the bone fragments do not fuse together within the expected healing timeframe, requiring further evaluation and management.

Causes

Direct trauma to the foot, such as a fall or impact, is the primary cause of the initial fracture. Nonunion may develop due to inadequate immobilization, poor blood supply to the bone, infection, or excessive movement during the healing process. Repetitive stress or delayed treatment of the original injury can also contribute to nonunion.

Risk Factors

• Participation in high-impact activities that stress the foot
• Smoking, which impairs bone healing
• Conditions that reduce blood flow or bone density (e.g., diabetes, osteoporosis)
• Previous foot injuries or surgeries
• Inadequate initial fracture management or immobilization

Symptoms

• Persistent pain and tenderness on the outer edge of the left foot
• Swelling or bruising that does not resolve over time
• Difficulty bearing weight or walking on the left foot
• Possible clicking or grinding sensation with movement

Diagnosis

A healthcare provider will assess the foot for persistent pain, swelling, and functional limitations. Imaging tests, such as X-rays or CT scans, are used to confirm nonunion by showing a visible gap between bone fragments or lack of healing progress. Additional tests may evaluate blood flow or bone density to identify contributing factors.

Treatment Options

• Immobilization with a cast or brace to stabilize the fracture and promote healing
• Bone stimulation therapies (e.g., electrical or ultrasound) to encourage bone growth
• Surgical intervention, such as bone grafting or internal fixation, to repair the nonunion
• Pain management with medications or physical therapy to improve mobility
• Lifestyle modifications to reduce stress on the foot during recovery

Prognosis and Follow-Up

Prognosis depends on the severity of nonunion and response to treatment. Most cases improve with appropriate management, but healing may take several months. Regular follow-up appointments and imaging are necessary to monitor progress. Full recovery often requires adherence to immobilization and activity restrictions.

Complications

• Chronic pain or instability in the left foot
• Increased risk of future fractures due to weakened bone
• Infection, particularly if surgery is performed
• Long-term mobility limitations or gait changes

Lifestyle & Prevention

• Wear supportive footwear to reduce foot stress
• Avoid high-impact activities until cleared by a healthcare provider
• Maintain a healthy diet rich in calcium and vitamin D to support bone health
• Quit smoking to improve healing outcomes
• Gradually resume activity under medical guidance to prevent re-injury

When to Seek Professional Help

Seek care if pain worsens, swelling increases, or mobility declines. Prompt evaluation is needed if signs of infection (e.g., redness, fever) or new deformity appear. Early intervention can improve healing and reduce complications.

Tips for Medical Coders

Document the encounter as a subsequent visit for fracture with nonunion. Include details on treatment provided, imaging results, and clinical assessment of healing status. Ensure documentation supports the nonunion diagnosis and aligns with the ICD-10-CM code S92.355K.