S82.65XK Nondisplaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture with nonunion

Name of the Condition

• Nondisplaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture with nonunion

Summary

A nondisplaced fracture of the lateral malleolus of the left fibula, with a subsequent encounter for closed fracture and nonunion, refers to a break in the outer bony prominence of the left ankle (part of the fibula) where the bone fragment remains in its normal anatomical position. The fracture is classified as closed (no skin penetration) and has not healed properly (nonunion) during follow-up care. This condition requires ongoing management to address the lack of bone healing and restore function.

Causes

Direct trauma to the left ankle, such as a fall or impact. Sudden twisting or rolling of the left ankle during activities. High-impact injuries, including sports or accidents. Inadequate initial treatment or immobilization may contribute to nonunion.

Risk Factors

• Participation in activities with high ankle stress (e.g., running, jumping).
• Osteoporosis or weakened bone density.
• Poor blood supply to the fracture site.
• Smoking or other factors that impair bone healing.
• Previous ankle injuries that may compromise stability.

Symptoms

• Persistent pain localized to the outer left ankle.
• Swelling and bruising around the fracture site.
• Difficulty bearing weight or walking.
• Minimal to no visible deformity (due to nondisplacement).
• Possible instability or discomfort during movement.

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 evaluate its alignment. Additional scans (e.g., CT or MRI) may be ordered to assess bone healing and identify nonunion. Clinical history of prior fracture and treatment is also considered.

Treatment Options

Treatment focuses on promoting bone healing and may include immobilization with a cast or brace, physical therapy to restore strength and mobility, and in some cases, surgical intervention (e.g., bone grafting or fixation) to address nonunion. Pain management and activity modification are also part of the plan.

Prognosis and Follow-Up

Prognosis depends on the success of treatment to achieve union. Regular follow-up with imaging is necessary to monitor healing progress. Nonunion may require extended treatment or surgery, and recovery time varies based on the individual case.

Complications

• Chronic pain or discomfort.
• Persistent instability of the ankle.
• Increased risk of future fractures.
• Potential need for surgical intervention.
• Delayed return to normal activities.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider.
• Use proper footwear and support during physical activity.
• Maintain bone health through diet and exercise.
• Follow post-treatment instructions carefully to support healing.

When to Seek Professional Help

Seek medical attention if pain worsens, swelling increases, or there is new deformity. Contact a provider if weight-bearing becomes impossible or if signs of infection (e.g., redness, fever) develop.

Tips for Medical Coders

Document the subsequent encounter for closed fracture with nonunion, including clinical notes confirming nonunion and the absence of skin penetration. Ensure the left fibula and lateral malleolus are clearly identified, and specify the encounter type (subsequent) and fracture status (closed, nonunion) to support accurate coding.