Displaced segmental fracture of shaft of left tibia, sequela

This code signifies a past injury involving a displaced fracture of the shaft of the left tibia, where the bone broke into at least three pieces (segmental). The "sequela" indicates that the patient is currently experiencing a residual condition or complication directly related to this old fracture, rather than the acute injury itself. This could include chronic pain, malunion, nonunion, deformity, or restricted range of motion.

Apply this code when documenting a patient presenting with a long-term complication or residual effect stemming from a previously sustained, displaced segmental fracture of the left tibial shaft. This is appropriate for follow-up encounters after the initial healing phase, where the focus is on managing the ongoing consequences of the fracture. Do not use for the initial acute injury.

• Always ensure documentation clearly links the current condition to the old fracture as a sequela.
• Code any specific sequela (e.g., malunion, nonunion, chronic osteomyelitis) as a primary diagnosis, with this code as a secondary.
• Verify laterality (left tibia) and fracture type (segmental, shaft) are explicitly stated in the medical record.