S82.866H Nondisplaced Maisonneuve's fracture of unspecified leg, subsequent encounter for open fracture type I or II with delayed healing

Name of the Condition

• Nondisplaced Maisonneuve's fracture of unspecified 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 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 "open fracture type I or II" designation refers to a fracture where the skin is breached, with type I involving a wound less than 1 cm and type II involving a wound 1–10 cm without extensive soft tissue damage or contamination. The "subsequent encounter" modifier indicates this is a follow-up visit for an established injury, and "delayed healing" signifies that the fracture is not progressing as expected toward union within the typical timeframe.

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. Open fractures occur when the force is sufficient to penetrate the skin, often due to high-energy trauma or a sharp bone fragment piercing the tissue. Delayed healing may result from factors such as poor blood supply, infection, inadequate immobilization, or underlying medical conditions affecting bone healing.

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, smoking, or nutritional deficiencies.

Symptoms

• Persistent pain at the fracture site despite immobilization.
• Swelling or bruising that does not improve over time.
• Difficulty bearing weight on the affected leg.
• Visible wound or scar from the open fracture (if applicable).
• Sensation of instability or looseness in the ankle joint.

Diagnosis

Diagnosis typically involves a physical examination to assess pain, swelling, and stability, along with imaging studies. X-rays are used to confirm the fracture and assess alignment, while CT or MRI may be ordered to evaluate soft tissue damage or delayed healing. The open fracture status is determined by examining the wound for size, depth, and contamination. Clinical judgment is used to identify delayed healing, which may be supported by serial imaging showing lack of progressive bone union over several weeks.

Treatment Options

Treatment focuses on stabilizing the fracture, promoting healing, and managing the open wound. Immobilization with a cast or brace is standard, and weight-bearing may be restricted. Surgical intervention may be considered for unstable fractures or persistent delayed healing, such as internal fixation or bone grafting. Open fractures require wound care, including cleaning and possible debridement, to prevent infection. Physical therapy is often introduced later to restore strength and mobility once healing progresses.

Prognosis and Follow-Up

Prognosis depends on the severity of the injury, adherence to treatment, and any underlying health factors. Most nondisplaced fractures heal with proper immobilization, but delayed healing may extend recovery time. Follow-up visits are scheduled to monitor healing through imaging and clinical assessment. Adjustments to treatment, such as extended immobilization or surgical intervention, may be made based on progress. Long-term outcomes generally include restored function, though some patients may experience residual stiffness or instability.

Complications

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

Lifestyle & Prevention

• Wear appropriate footwear for activities to reduce rotational stress.
• Maintain good bone health through diet and exercise to support healing.
• Avoid high-risk activities if you have a history of ankle instability.
• Follow post-injury care instructions closely to minimize complications.
• Quit smoking and manage chronic conditions to optimize healing.

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., redness, pus, fever). Contact your healthcare provider if symptoms worsen or do not improve with treatment, or if you notice new swelling, bruising, or instability.

Tips for Medical Coders

Document the fracture type (open I or II), encounter stage (subsequent), and healing status (delayed) clearly in the medical record. Ensure the open fracture classification aligns with wound size and tissue damage. Note any contributing factors to delayed healing, such as infection or poor immobilization, to support code specificity. Verify that the leg (unspecified) is documented if no further detail is available.