S82.865G Nondisplaced Maisonneuve's fracture of left leg, subsequent encounter for closed fracture with delayed healing

Name of the Condition

• Nondisplaced Maisonneuve's fracture of left leg, subsequent encounter for closed fracture with delayed healing

Summary

A Maisonneuve's fracture is a specific type of ankle injury involving a fracture of the proximal fibula (upper portion of the smaller lower leg bone) combined with a tear of the syndesmotic ligaments and often an associated injury to the medial malleolus or deltoid ligament. The term "nondisplaced" indicates that the fractured bone fragments remain aligned. This injury typically results from rotational forces applied to the ankle, commonly seen in trauma such as falls or sports injuries. The "subsequent encounter for closed fracture with delayed healing" specifies this is a follow-up visit for a fracture that has not healed within the expected timeframe, without an open wound.

Causes

The fracture is caused by external rotational forces applied to the ankle, often during activities that involve twisting or turning. Common scenarios include falls, motor vehicle accidents, or sports-related impacts where the foot is planted and the body rotates forcefully. The mechanism typically involves the talus rotating outward, stressing the syndesmotic ligaments and causing the proximal fibula to fracture. Delayed healing may occur due to factors such as poor blood supply, inadequate immobilization, or underlying health conditions affecting bone repair.

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.
• Conditions like diabetes or smoking that impair healing.

Symptoms

• Persistent 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."
• Possible bruising or tenderness over the fracture site.
• Delayed healing may present with prolonged pain or lack of radiographic evidence of bone union.

Diagnosis

Diagnosis involves a thorough clinical evaluation, including a detailed history of the injury and physical examination to assess pain, swelling, and stability. Imaging studies, such as X-rays or CT scans, are typically used to confirm the fracture and assess alignment. Additional tests, like MRI, may be ordered to evaluate soft tissue damage or delayed healing. The "subsequent encounter" designation implies prior documentation of the fracture and treatment, with follow-up imaging to assess healing progress.

Treatment Options

Treatment focuses on stabilizing the fracture and promoting healing. This may include immobilization with a cast or brace, activity modification, and pain management. Physical therapy is often recommended to restore strength and mobility once healing progresses. In cases of delayed healing, additional interventions such as bone stimulation or surgical fixation may be considered. Follow-up care is essential to monitor healing and adjust treatment as needed.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture, adherence to treatment, and individual healing factors. Most nondisplaced fractures heal with proper immobilization and time, but delayed healing may prolong recovery. Regular follow-up appointments are necessary to assess progress, adjust treatment, and ensure the fracture is healing appropriately. Long-term outcomes may include restored function, though some patients may experience residual stiffness or instability.

Complications

• Delayed or nonunion of the fracture.
• Chronic ankle instability or pain.
• Post-traumatic arthritis due to joint damage.
• Nerve or vascular injury in severe cases.
• Infection (rare, but possible with open fractures or surgery).

Lifestyle & Prevention

• Wear appropriate footwear for activities to reduce fall risk.
• Strengthen ankle muscles through targeted exercises.
• Avoid high-impact activities until cleared by a healthcare provider.
• Maintain a healthy lifestyle to support bone healing, including adequate nutrition and avoiding smoking.

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). Follow up with a healthcare provider if symptoms worsen or do not improve with treatment, or if you notice persistent swelling or instability.

Tips for Medical Coders

Document the fracture type (nondisplaced), laterality (left leg), encounter type (subsequent), and healing status (delayed healing) clearly. Ensure clinical notes support the "delayed healing" designation, as this impacts coding and may require additional documentation of healing progress. Verify that the fracture is closed (no open wound) and that the encounter is for follow-up care, not initial treatment.