S82.864E Nondisplaced Maisonneuve's fracture of right leg, subsequent encounter for open fracture type I or II with routine healing

Name of the Condition

• Nondisplaced Maisonneuve's fracture of right leg, subsequent encounter for open fracture type I or II with routine healing

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 in their normal alignment. This injury typically results from rotational forces applied to the ankle, leading to instability in the ankle joint. The "subsequent encounter" designation specifies this is a follow-up visit after the initial treatment, and "open fracture type I or II with routine healing" indicates the fracture site has an open wound (type I: <1 cm, type II: 1–10 cm) that is healing without complications.

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. The open nature of the fracture suggests the injury involved a forceful impact that broke the skin, such as a direct blow or a severe twist.

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.
• Age-related factors that may affect bone density or ligament integrity.

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."
• Visible or palpable wound at the fracture site (for open fractures).
• Possible bruising or discoloration around the injury.

Diagnosis

Diagnosis typically involves a physical examination to assess pain, swelling, and stability, followed by imaging studies such as X-rays to confirm the fracture and its alignment. Additional imaging, like CT or MRI, may be used to evaluate associated ligament or soft tissue damage. The "subsequent encounter" and "routine healing" status are determined by clinical assessment of wound closure and fracture stability during follow-up visits.

Treatment Options

Treatment focuses on maintaining alignment, promoting healing, and restoring function. This may include immobilization with a cast or brace, pain management, and physical therapy to improve strength and mobility. For open fractures, wound care is essential to prevent infection. Surgical intervention is rarely needed for nondisplaced fractures but may be considered if instability persists.

Prognosis and Follow-Up

With proper treatment, most nondisplaced Maisonneuve's fractures heal well, and patients can return to normal activities. Follow-up visits monitor healing progress, wound status, and functional recovery. Routine healing indicates the fracture is progressing without complications, but ongoing assessment ensures no delayed issues arise.

Complications

• Infection (for open fractures).
• Delayed union or nonunion of the fracture.
• Chronic ankle instability or pain.
• Post-traumatic arthritis.
• Nerve or vascular damage (rare).

Lifestyle & Prevention

• Wear supportive footwear appropriate for activities.
• Use ankle braces or supports during high-risk sports.
• Improve balance and strength through exercises.
• Avoid uneven surfaces or hazardous environments.
• Seek prompt treatment for ankle injuries to prevent progression.

When to Seek Professional Help

• Increased pain, swelling, or redness at the injury site.
• Fever or signs of infection (e.g., pus, warmth).
• New or worsening instability when bearing weight.
• Numbness, tingling, or changes in skin color (possible vascular or nerve issues).
• Failure of the wound to heal or signs of dehiscence.

Tips for Medical Coders

Document the encounter type (subsequent), fracture type (open I or II), and healing status (routine) clearly. Ensure clinical notes specify the fracture's alignment (nondisplaced) and any associated injuries. Verify the laterality (right leg) and confirm the fracture is healing without complications to support the code assignment.