In simple words: A torus (buckle) fracture at the top of the shinbone hasn't healed correctly. This follow-up visit addresses the improperly healed fracture. It commonly occurs in toddlers and young children.

A torus fracture, also known as a buckle fracture, is an incomplete fracture of the bone characterized by a bulging or buckling of the bone cortex. This type of fracture typically occurs in young children at the upper end of the tibia (shinbone). This code specifies that the fracture is located at the upper end of the tibia, the side is unspecified, and it is a subsequent encounter for a malunion, which means the fracture has not healed properly.

Example 1: A 4-year-old child had a torus fracture of the upper tibia a few weeks ago. The child now presents with persistent pain and deformity at the fracture site. Imaging reveals the fracture has healed with malunion. , A 3-year-old child experienced a fall and sustained a torus fracture of their upper tibia. The child was treated with a splint, and today, is a follow-up visit. The imaging taken today shows that the bone is healing but with angulation., A young child was previously treated for a torus fracture of the upper tibia with immobilization, and it is not healing properly.

Confirm laterality (right or left), document the location – upper tibia (proximal tibia) and the type of fracture (torus/buckle). It should be clearly documented as a subsequent encounter related to the previous torus fracture. The documentation should also state the evidence of malunion, such as persistent pain, deformity, or imaging results.