Nondisplaced spiral fracture of shaft of left tibia, sequela

This code describes the long-term effects or complications arising from a previously sustained, nondisplaced spiral fracture of the shaft of the left tibia. It indicates that the initial fracture has healed, but the patient is still experiencing residual issues directly attributable to that injury.

Use this code when documenting ongoing problems such as chronic pain, limited range of motion, nonunion, malunion, or other persistent functional impairments in the left lower leg, specifically linked to a past nondisplaced spiral tibia shaft fracture. This code is appropriate for follow-up encounters after the initial healing phase of the fracture.

• Requires an additional code to specify the nature of the sequela (e.g., M25.562 for chronic pain in left knee, M21.962 for unspecified deformity of left lower leg).
• Ensure documentation clearly links the current condition as a direct consequence of the historical fracture.
• Do not use for initial or subsequent encounters during the active treatment and healing phase of the fracture.