S82.51XG Displaced fracture of medial malleolus of right tibia, subsequent encounter for closed fracture with delayed healing

ICD10CM code

#### Name of the Condition
- Displaced fracture of medial malleolus of right tibia, subsequent encounter for closed fracture with delayed healing

#### Summary
A displaced fracture of the medial malleolus of the right tibia involves a break in the inner bone of the lower leg, near the ankle. This specific encounter refers to a follow-up after initial treatment, where healing is slower than expected, but the skin remains intact over the fracture.

#### Causes
- High-impact injuries such as falls, sports injuries, or car accidents are common causes.
- Osteoporosis or other bone-weakening conditions can predispose individuals to fractures.

#### Risk Factors
- Participation in contact sports or high-risk activities.
- Previous ankle injuries.
- Bone diseases, such as osteoporosis or osteopenia.

#### Symptoms
- Persistent pain and swelling around the ankle.
- Difficulty bearing weight on the affected leg.
- Bruising and tenderness at the fracture site.

#### Diagnosis
- Physical examination of the affected area.
- Imaging tests, such as X-rays or CT scans, to evaluate the fracture and healing progress.

#### Treatment Options
- Cast or brace to immobilize the fracture and allow healing.
- Physical therapy to regain strength and mobility post-healing.
- Pain management with medications.
- Surgery might be required if delayed healing persists, involving fixation with screws or plates.

#### Prognosis and Follow-Up
- With appropriate treatment, most individuals recover well, although delayed healing can extend recovery time.
- Regular follow-up appointments are crucial to monitor healing progress and adjust treatment as necessary.

#### Complications
- Possible complications include non-union or malunion of the bone, arthritis, or chronic pain if not properly managed.

#### Lifestyle & Prevention
- Maintain a healthy diet rich in calcium and vitamin D for bone health.
- Regularly engage in weight-bearing exercises to strengthen bones.
- Wear proper footwear to minimize the risk of falls and injuries.

#### When to Seek Professional Help
- Seek immediate medical attention if there is sudden severe pain, increased swelling, or if the fracture area shows signs of infection such as redness, warmth, or discharge.

#### Additional Resources
- American Orthopaedic Foot & Ankle Society (AOFAS): [www.aofas.org](https://www.aofas.org)
- National Osteoporosis Foundation: [www.nof.org](https://www.nof.org)

#### Tips for Medical Coders
- Ensure the specificity of coding by confirming the fracture is a displaced fracture on the right tibia with delayed healing.
- Avoid common errors like coding for the initial encounter or for an open fracture when it is classified as a closed fracture.

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