S82.864A Nondisplaced Maisonneuve's fracture of right leg, initial encounter for closed fracture

Name of the Condition

• Nondisplaced Maisonneuve's fracture of right leg, initial encounter for closed fracture

Summary

A Maisonneuve's fracture is a specific type of ankle injury involving a proximal fibula fracture combined with a tear of the tibiofibular syndesmosis and often an associated medial malleolus or deltoid ligament injury. The term "nondisplaced" indicates that the fractured bone fragments remain aligned. This injury typically results from rotational forces applied to the ankle, leading to instability in the ankle joint. The "initial encounter for closed fracture" specifies this is the first treatment for a fracture without an open wound.

Causes

The fracture is usually caused by external rotation of the foot, which can occur during activities like twisting the ankle, falls, or sports-related injuries. The rotational force disrupts the syndesmotic ligaments and may cause additional damage to the medial structures of the ankle.

Risk Factors

• Participation in activities with high rotational stress on the ankle, such as soccer or basketball.
• Previous ankle injuries or ligamentous instability.
• Improper footwear or uneven terrain increasing fall risk.

Symptoms

• Pain and swelling localized to the proximal fibula and ankle.
• Difficulty bearing weight on the affected leg.
• Instability or a feeling of the ankle "giving way."
• Bruising or tenderness along the lower leg.

Diagnosis

Diagnosis involves a physical examination to assess ankle stability, tenderness, and swelling. Imaging, typically X-rays, is used to identify the proximal fibula fracture and associated injuries. Additional imaging, such as CT or MRI, may be required to evaluate ligament damage or confirm the fracture is nondisplaced.

Treatment Options

Treatment focuses on stabilizing the ankle and allowing healing. Options include immobilization with a cast or brace, pain management, and physical therapy to restore strength and mobility. Surgical intervention is less common for nondisplaced fractures but may be considered if instability persists.

Prognosis and Follow-Up

Prognosis is generally favorable with proper treatment, though recovery may take several weeks to months. Follow-up appointments monitor healing, assess ankle stability, and guide rehabilitation. Long-term outcomes depend on the extent of ligament damage and adherence to treatment plans.

Complications

Potential complications include chronic ankle instability, post-traumatic arthritis, or delayed union of the fracture. Infection is rare but possible if surgical intervention is required.

Lifestyle & Prevention

• Wear supportive footwear during high-risk activities.
• Strengthen ankle muscles through targeted exercises.
• Avoid uneven surfaces or situations that increase fall risk.
• Use proper techniques in sports to minimize rotational stress on the ankle.

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., fever, redness, drainage) after an injury.

Tips for Medical Coders

Document the fracture location (right leg), displacement status (nondisplaced), encounter type (initial), and fracture type (closed) to accurately assign code S82.864A. Ensure clinical notes specify the absence of open wounds and confirm the initial treatment phase to support coding accuracy.