Name of the Condition

• Breakdown (mechanical) of internal fixation device of bone of right lower leg, initial encounter
• ICD Code: T84.116A

Summary

• This condition refers to the failure or malfunction of a medical device, such as a rod, screw, or plate, surgically implanted to stabilize or support a fracture in the right lower leg. This specific code represents the first visit or assessment after the mechanical failure is identified.

Causes

• The mechanical breakdown can be caused by improper placement, manufacturing defects, excessive physical stress, or wear and tear over time. Trauma or impact to the leg can also lead to device failure.

Risk Factors

• High-intensity physical activity, obesity, completion of certain types of surgeries, poor bone health, and previous history of similar device issues are factors that increase the likelihood of mechanical breakdowns.

Symptoms

• Patients may experience pain, swelling, instability in the leg, changes in leg alignment, and occasionally, visible deformity or mobility issues.

Diagnosis

• Diagnosis typically involves physical examination, patient history assessment, and imaging tests such as X-rays, CT scans, or MRIs to visualize the device and surrounding bone structure.

Treatment Options

• Treatment may include revision surgery to repair or replace the device, physical therapy to restore function, and medication for pain management. The choice of treatment depends on the extent of the failure and patient health status.

Prognosis and Follow-Up

• Prognosis varies with prompt treatment often leading to recovery of leg function. Regular follow-ups are essential to monitor healing and ensure proper positioning and function of any new or repaired devices.

Complications

• Potential complications may include infection, impaired mobility, or non-union of the bone. A breakdown can also lead to misalignment or additional fractures if not addressed promptly.

Lifestyle & Prevention

• Engage in moderate, low-impact exercises to maintain bone health, adhere to postoperative guidelines, and attend all follow-up appointments. Avoid activities that put undue stress on the affected limb.

When to Seek Professional Help

• Immediate medical attention is necessary if there is severe pain, noticeable instability, or any signs of infection (e.g., fever, redness, warmth around the surgical site).

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS)
• Orthopaedic Trauma Association (OTA)
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Tips for Medical Coders

• Ensure the correct laterality (right lower leg) and initial encounter status are accurately recorded.
• Verify any accompanying injury codes if the breakdown was due to trauma.
• Be cautious with the sequence of codes to align with treatment and follow-up procedures.