S82.855 Nondisplaced trimalleolar fracture of left lower leg

Name of the Condition

• Nondisplaced trimalleolar fracture of left lower leg
• ICD-10 Code: S82.855

Summary

A nondisplaced trimalleolar fracture of the left lower leg involves a break in all three malleoli (medial, lateral, and posterior) of the ankle joint, with bone fragments remaining in their normal alignment. This injury typically results from high-impact trauma and may require stabilization to maintain joint integrity. The fracture disrupts the ankle's structural stability, affecting weight-bearing and mobility.

Causes

Trimalleolar fractures commonly result from severe trauma, such as falls from height, motor vehicle accidents, or sports-related impacts. Twisting injuries or direct force to the ankle can also cause this type of fracture, which involves multiple bony components of the joint.

Risk Factors

• Participation in high-impact sports or activities with fall risks.
• Advanced age, leading to reduced bone density.
• Osteoporosis or other bone-weakening conditions.
• Previous ankle injuries or joint instability.

Symptoms

• Intense pain, swelling, and bruising around the ankle.
• Inability to bear weight on the affected leg.
• Visible deformity or misalignment of the ankle joint.
• Tenderness, instability, or numbness in the foot or ankle.

Diagnosis

Diagnosis begins with a physical examination to assess pain, swelling, and deformity. Imaging tests, such as X-rays or CT scans, are used to confirm the fracture and evaluate alignment. Additional tests may be performed to rule out associated injuries.

Treatment Options

Treatment depends on fracture severity and stability. Nondisplaced fractures may be managed with immobilization (e.g., casting or bracing) and non-weight-bearing protocols. Surgical intervention may be required if instability or displacement occurs. Physical therapy is often recommended during recovery to restore function.

Prognosis and Follow-Up

Prognosis is generally favorable with proper treatment, though recovery time varies. Follow-up appointments monitor healing and alignment. Long-term outcomes depend on fracture complexity, treatment adherence, and rehabilitation. Most patients regain full mobility, but some may experience residual stiffness or weakness.

Complications

Potential complications include infection, delayed healing, or malunion. Nerve or vascular damage, post-traumatic arthritis, or chronic pain may also occur. Early intervention reduces these risks.

Lifestyle & Prevention

Avoid high-risk activities without proper protection. Maintain bone health through diet and exercise. Use supportive footwear and practice fall prevention strategies, especially in older adults.

When to Seek Professional Help

Seek immediate care for severe pain, swelling, or inability to bear weight. Contact a healthcare provider if symptoms worsen or new issues (e.g., numbness, discoloration) develop during recovery.

Tips for Medical Coders

Document the fracture's location (left lower leg) and alignment (nondisplaced) to support accurate coding. Include details on imaging, treatment, and follow-up to ensure comprehensive record-keeping. Verify that all three malleoli are involved to confirm the trimalleolar classification.