Individuals participating in high-risk sports are mainly at the risk of tibia and fibula fractures. A recent injury case at Rio Olympics 2016 is that of the 26-year-old French gymnast Samir Ait Said. During the qualification rounds for the men’s gymnastics, Said suffered a horrific leg injury as he attempted a vault. It was reported that the sickening sound of his leg snapping echoed throughout the arena. After a botched landing, his left leg dangled at a horrible angle. According to the French Gymnastics Federation, the gymnast broke both his tibia and fibia. Several reports say that Samir most likely sustained a transverse or oblique tibia shaft fracture involving the fibula. Said was qualified for the final on still rings. He had surgery and has been reported walking in hospital.
The gymnast, who was likely to make it to the final, is a four-time European championships medalist on rings, including gold in 2013. However, this is not the first time an injury stops Said’s Olympic dreams. The gymnast was taken out of the 2012 Games as he fractured his right leg in three places during the European Championships.
Tibial fractures are the most common long bone fractures encountered by orthopedic surgeons. The most important causes of tibial fractures are road traffic accidents, sports injuries, direct blows or assault, falls and gunshot injuries. As in Said’s case, for an open fracture, where the bone is poking through the skin, surgery is recommended to wash out the fracture before stabilizing, and thus minimize the chance of later infection.
In certain cases, even open fractures can be associated with a compartment syndrome, which comes with signs including stretch pain and loss of sensation. Acute compartment syndrome is treated with fasciotomy (release the muscle compartments).
Such sports injury treatments are reimbursed. For the condition to be coded accurately, providers should also document the specific type of fracture. The ICD-10 code set comes with options for specific types of fractures, helping clear and accurate provider documentation. For fractures related to tibia or fibula, the following codes can be used.
- S82.2 Fracture of shaft of tibia
- S82.202 Unspecified fracture of shaft of left tibia
- S82.222 Displaced transverse fracture of shaft of left tibia
- S82.225 Non-displaced transverse fracture of shaft of left tibia
- S82.232 Displaced oblique fracture of shaft of left tibia
- S82.235 Non-displaced oblique fracture of shaft of left tibia
- S82.11 Fracture of upper end of tibia, open
- S82.21 Fracture of shaft of tibia, open
- S82.31 Fracture of lower end of tibia, open
- S82.81 Fractures of other parts of lower leg, open
- S82.91 Fracture of lower leg, part unspecified, open
Medical billing companies providing medical coding assistance for orthopedic surgeons make sure that they report seventh character A (initial encounter) while the patient is receiving active treatment for the injury, for e.g., surgical treatment, ED encounter or Evaluation and treatment by a new physician, such as “S82.401A – initial encounter for closed fracture”.