S82.845 Nondisplaced bimalleolar fracture of left lower leg

Name of the Condition

• Nondisplaced bimalleolar fracture of left lower leg
• ICD-10 Code: S82.845

Summary

A nondisplaced bimalleolar fracture of the left 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 is nondisplaced, meaning bone fragments remain in their normal alignment. This injury typically affects the ankle joint and may result in instability due to the involvement of both bones. It often occurs from trauma that disrupts the structural integrity of the ankle.

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 without shifting out of alignment. 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.
• Visible deformity or misalignment of the ankle joint.
• Tenderness and instability when attempting movement.

Diagnosis

Diagnosis begins with a physical examination to assess pain, swelling, and deformity. Imaging, such as X-rays, confirms the fracture and verifies that bone fragments are not displaced. CT or MRI may be used for detailed visualization of complex injuries or associated soft tissue damage.

Treatment Options

Treatment depends on the severity of the fracture and patient factors. Nondisplaced fractures may be managed with immobilization using a cast or brace, followed by gradual weight-bearing as healing progresses. Pain management and physical therapy are often recommended to restore function. Surgical intervention is typically unnecessary unless instability or associated injuries are present.

Prognosis and Follow-Up

Most nondisplaced bimalleolar fractures heal well with proper immobilization and rehabilitation. Full recovery may take several weeks to months, depending on the patient’s age and overall health. Follow-up appointments are essential to monitor healing and adjust treatment plans as needed. Physical therapy may be recommended to restore strength and mobility.

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 ankle injury risk.
• Maintain bone health through adequate calcium and vitamin D intake.
• Avoid high-risk activities or use protective gear when participation is necessary.
• Perform ankle-strengthening exercises to improve stability.

When to Seek Professional Help

Seek immediate medical attention if you experience severe ankle pain, swelling, or deformity after an injury. Prompt evaluation is important to confirm the diagnosis and initiate appropriate treatment. Contact a healthcare provider if symptoms worsen or fail to improve with initial care.

Tips for Medical Coders

Document the specific laterality (left lower leg) and fracture status (nondisplaced) to ensure accurate coding. Include details about the mechanism of injury, imaging findings, and treatment provided, as these may support code assignment. Verify that the fracture involves both malleoli and confirm no displacement to align with the code’s definition.