Sltr-haris Type II physl fx upper end of unsp tibia, sequela

This code signifies a Salter-Harris Type II fracture affecting the growth plate at the proximal (upper) end of the tibia, where the fracture line extends through the physis and into the metaphysis. The "sequela" designation indicates that this code is used for conditions that are the late effects or complications of the original injury, after the acute phase has passed. The specific location is unspecified, meaning it could be either the left or right tibia.

This code is appropriate when documenting long-term complications, deformities, or functional limitations directly resulting from a previously sustained Salter-Harris Type II fracture of the upper tibia. Examples include growth arrest, angular deformity, leg length discrepancy, or chronic pain attributed to the healed fracture. It should be used after the initial acute injury has been treated and the patient is presenting for follow-up of these persistent issues.

• Always sequence the sequela code first, followed by any codes for the specific manifestation of the sequela (e.g., growth arrest).
• Ensure documentation clearly links the current condition to the previous Salter-Harris Type II fracture of the upper tibia.
• Avoid using this code for the initial acute injury; a different code would be used for the active fracture treatment.