Unspecified fracture of upper end of unspecified tibia
ICD-10 S82.109 is a billable code used to indicate a diagnosis of unspecified fracture of upper end of unspecified tibia.
The unspecified fracture of the upper end of the tibia refers to a break in the proximal region of the tibia, which is the larger of the two bones in the lower leg. This type of fracture can occur due to various mechanisms, including falls, sports injuries, or vehicular accidents. The upper end of the tibia is critical as it forms part of the knee joint, and fractures in this area can lead to significant complications, including joint instability, malunion, or nonunion. Symptoms typically include localized pain, swelling, and difficulty bearing weight on the affected leg. Diagnosis is often confirmed through imaging studies such as X-rays or MRI, which can help assess the extent of the fracture and any associated soft tissue injuries, such as ligament tears. Treatment may involve conservative management with immobilization or surgical intervention, depending on the fracture's severity and the patient's overall health. Rehabilitation is crucial for restoring function and strength to the knee joint post-injury.
Detailed descriptions of the fracture type, location, and any associated injuries must be documented. Surgical notes should include the procedure performed and any implants used.
Fractures resulting from sports injuries, falls, or trauma requiring surgical intervention.
Ensure that all imaging studies and consultations are documented to support the diagnosis and treatment plan.
Documentation should include the patient's functional status, rehabilitation goals, and progress notes.
Patients undergoing rehabilitation post-fracture for strength and mobility restoration.
Focus on documenting the patient's response to therapy and any complications that may arise during rehabilitation.
Used when surgical intervention is required for fracture stabilization.
Operative reports must detail the procedure performed and any implants used.
Orthopedic surgeons should ensure that all relevant imaging and pre-operative assessments are documented.
Use S82.109 when the documentation does not specify the type or side of the fracture. If more specific information is available, opt for the appropriate specific code.
