S82.865H Nondisplaced Maisonneuve's fracture of left leg, subsequent encounter for open fracture type I or II with delayed healing

Name of the Condition

• Nondisplaced Maisonneuve's fracture of left leg, subsequent encounter for open fracture type I or II 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" designation indicates this is a follow-up visit for an established injury, while "open fracture type I or II" refers to a break in the skin with minimal contamination or a small wound, respectively. "Delayed healing" signifies that the fracture is not progressing as expected during the normal healing timeline.

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. Open fractures occur when the broken bone pierces the skin, often due to high-energy trauma or direct impact. Delayed healing may result from factors such as poor blood supply, infection, or inadequate immobilization.

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 that impair healing, such as diabetes or smoking.

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."
• Visible or palpable wound at the fracture site (for open fractures).
• Delayed healing signs, such as lack of progress on imaging or prolonged pain.

Diagnosis

Diagnosis typically involves a physical examination to assess pain, swelling, and instability. Imaging studies, such as X-rays, are used to confirm the fracture and assess alignment. CT or MRI may be ordered to evaluate associated ligament injuries or soft tissue damage. For open fractures, the wound is examined for contamination or infection. Delayed healing is diagnosed when imaging shows insufficient bone callus formation or persistent fracture lines over time.

Treatment Options

Treatment focuses on stabilizing the fracture and promoting healing. Non-surgical options include immobilization with a cast or brace, followed by gradual weight-bearing as healing progresses. Surgical intervention may be required for unstable fractures or open wounds, involving fixation of the fibula and repair of ligaments. For delayed healing, additional interventions such as bone grafting, electrical stimulation, or adjusted immobilization may be considered. Open fractures require wound care to prevent infection.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture, associated injuries, and adherence to treatment. Nondisplaced fractures generally heal well with proper care, but delayed healing may prolong recovery. Follow-up visits are necessary to monitor healing progress through imaging and clinical assessment. Physical therapy is often recommended to restore strength and mobility once healing is underway.

Complications

• Infection, particularly with open fractures.
• Nonunion or malunion of the fracture.
• Chronic ankle instability or arthritis.
• Nerve or vascular damage from the injury or surgery.
• Prolonged pain or functional limitations.

Lifestyle & Prevention

• Wear appropriate footwear for activities to reduce rotational stress.
• Avoid uneven terrain or surfaces that increase fall risk.
• Strengthen ankle muscles through targeted exercises.
• Use protective gear during high-risk sports.
• Address underlying conditions that impair healing, such as diabetes.

When to Seek Professional Help

Seek immediate medical attention if there is severe pain, inability to bear weight, visible deformity, or signs of infection (e.g., redness, pus, fever). Follow up with a healthcare provider if symptoms worsen or do not improve with treatment, or if there are concerns about delayed healing.

Tips for Medical Coders

Document the fracture type (nondisplaced), laterality (left leg), encounter type (subsequent), open fracture classification (type I or II), and delayed healing status clearly. Ensure clinical notes support the "subsequent encounter" designation by referencing prior treatment or established care. For open fractures, document the wound characteristics to confirm type I or II. Delayed healing should be supported by imaging or clinical findings indicating prolonged healing.