S82.64 Nondisplaced fracture of lateral malleolus of right fibula

Name of the Condition

• Nondisplaced fracture of lateral malleolus of right fibula

Summary

A nondisplaced fracture of the lateral malleolus of the right fibula is a break in the outer bony prominence of the right ankle (part of the fibula) where the bone remains aligned despite the injury. This type of fracture typically results from trauma, such as a fall or twisting motion, and does not involve the bone fragment shifting out of its normal position.

Causes

Traumatic injuries, including falls, sports-related impacts, or sudden twisting of the ankle. Direct force to the outer ankle, such as from a blow or collision, can also cause this fracture.

Risk Factors

• Participation in high-impact activities or sports that stress the ankle.
• Osteoporosis or weakened bone density, which increases fracture risk.
• Previous ankle injuries that may compromise structural integrity.
• Age-related bone fragility, particularly in older adults.

Symptoms

• Pain localized to the outer right ankle.
• Swelling and tenderness around the fracture site.
• Bruising in the ankle area.
• Difficulty bearing weight or walking on the affected leg.
• Limited range of motion in the ankle.

Diagnosis

Diagnosis involves a physical examination to assess pain, swelling, and range of motion. Imaging tests, such as X-rays, are used to confirm the fracture and verify that it is nondisplaced. Additional scans (e.g., CT or MRI) may be ordered if further detail is needed, particularly if the initial imaging is inconclusive.

Treatment Options

• Rest, ice, compression, and elevation (RICE) to reduce swelling and pain.
• Immobilization with a cast or splint to stabilize the fracture and promote healing.
• Over-the-counter pain relievers, such as ibuprofen or acetaminophen, to manage discomfort.
• Physical therapy to restore strength and mobility once healing progresses.

Prognosis and Follow-Up

With proper care, most nondisplaced fractures of the lateral malleolus heal well. Follow-up appointments are typically scheduled to monitor healing through imaging and assess functional recovery. Return to normal activities depends on the individual’s healing progress and may take several weeks to months.

Complications

• Delayed healing or nonunion if the fracture does not heal properly.
• Chronic pain or stiffness in the ankle.
• Increased risk of future ankle injuries due to residual weakness.
• Rarely, nerve or blood vessel damage near the fracture site.

Lifestyle & Prevention

• Wear supportive footwear, especially during activities that stress the ankles.
• Strengthen ankle muscles through targeted exercises to improve stability.
• Avoid uneven surfaces or high-risk activities without proper protection.
• Maintain bone health through adequate calcium and vitamin D intake, particularly for those with osteoporosis.

When to Seek Professional Help

Seek immediate medical attention if you experience severe pain, inability to bear weight, visible deformity, or signs of infection (e.g., redness, warmth, or pus) around the ankle. Persistent pain or swelling after initial treatment also warrants evaluation.

Tips for Medical Coders

When coding for a nondisplaced fracture of the lateral malleolus of the right fibula, use the ICD-10-CM code S82.64. Ensure documentation specifies the fracture is nondisplaced and involves the right fibula. Include details about the encounter type (e.g., initial, subsequent) and whether the fracture is open or closed, as these affect code selection. Verify that the laterality (right) and anatomical site (lateral malleolus of fibula) are clearly documented to support accurate coding.