S82.844 Nondisplaced bimalleolar fracture of right lower leg

Name of the Condition

• Nondisplaced bimalleolar fracture of right lower leg
• ICD-10 Code: S82.844

Summary

A nondisplaced bimalleolar fracture of the right lower leg involves a break in both the medial (inner) and lateral (outer) malleoli, the bony prominences at the distal end of the tibia and fibula. The fracture fragments remain in their normal alignment, preserving the structural integrity of the ankle joint. This injury typically results from trauma that disrupts the ankle's stability without causing significant displacement.

Causes

Nondisplaced bimalleolar fractures commonly result from high-impact trauma, such as falls, motor vehicle accidents, or sports-related injuries. Direct force to the ankle, particularly when the foot is in a fixed position, can cause both malleoli to fracture simultaneously. Twisting or rotational forces may also contribute to this type of injury.

Risk Factors

• Participation in activities with a high risk of ankle trauma, such as contact sports or skiing.
• Advanced age, which may lead to decreased bone density and increased fracture susceptibility.
• Conditions that weaken bone structure, such as osteoporosis or metabolic disorders.
• Previous ankle injuries or surgeries that compromise joint stability.

Symptoms

• Severe pain, swelling, and bruising around the ankle.
• Inability to bear weight on the affected leg.
• Tenderness and instability when attempting movement.
• Possible audible snap or pop at the time of injury.

Diagnosis

Diagnosis begins with a physical examination to assess pain, swelling, and deformity. Imaging, such as X-rays, confirms the fracture and verifies that fragments remain aligned. CT or MRI may be used for detailed visualization of complex injuries or associated soft tissue damage.

Treatment Options

Treatment typically involves immobilization with a cast or brace to allow healing. Non-displaced fractures may not require surgery, but close monitoring is essential. Pain management and physical therapy are often recommended to restore function and strength.

Prognosis and Follow-Up

Prognosis is generally favorable with proper immobilization and adherence to treatment plans. Follow-up appointments are necessary to monitor healing and ensure no displacement occurs. Most patients regain full function, though recovery time varies based on injury severity and individual health factors.

Complications

• Delayed healing or nonunion of the fracture.
• Post-traumatic arthritis due to joint damage.
• Chronic pain or instability in the ankle.
• Nerve or vascular injury in severe cases.

Lifestyle & Prevention

• Wear appropriate footwear for activities to reduce fall risk.
• Maintain bone health through diet and exercise to strengthen bones.
• Avoid high-impact activities without proper protection.
• Use caution on uneven surfaces to prevent ankle twists or falls.

When to Seek Professional Help

Seek immediate medical attention if severe pain, swelling, or deformity occurs after an injury. Contact a healthcare provider if symptoms worsen or if weight-bearing becomes impossible, as these may indicate complications.

Tips for Medical Coders

Document the nondisplaced nature of the fracture and specify the right lower leg involvement. Ensure clinical notes confirm both malleoli are affected and no displacement is present. Code S82.844 is specific to the right side; verify laterality and fracture details match documentation.