S92.0 Fracture of calcaneus

Name of the Condition

• Fracture of calcaneus
• Medical term: Calcaneal fracture

Summary

This condition refers to a break or crack in the calcaneus, the large bone that forms the heel of the foot. It is a common injury resulting from trauma and can vary in severity, affecting mobility and weight-bearing ability.

Causes

High-impact trauma, such as falls from a height or automobile accidents. Direct force to the heel, often seen in sports injuries or workplace accidents.

Risk Factors

• Engaging in high-impact activities or sports.
• Osteoporosis or other bone-weakening conditions.
• Improper footwear or uneven surfaces that increase fall risk.

Symptoms

• Sudden, severe pain in the heel or foot.
• Swelling, bruising, or tenderness around the heel.
• Difficulty or inability to bear weight on the affected foot.
• Possible deformity if the fracture is displaced.

Diagnosis

Physical examination to assess pain, swelling, and range of motion. Imaging tests, such as X-rays or CT scans, to confirm the fracture and evaluate its extent.

Treatment Options

• Rest and immobilization with a cast or splint to allow healing.
• Pain management with medications or ice therapy.
• Surgical intervention for severe or displaced fractures to realign the bone.

Prognosis and Follow-Up

Healing time varies, typically 6–12 weeks, depending on fracture severity. Follow-up imaging may be needed to monitor bone union. Physical therapy may be recommended to restore strength and mobility.

Complications

• Chronic pain or arthritis in the ankle or subtalar joint.
• Nerve damage or numbness in the foot.
• Nonunion or malunion of the fracture if not properly treated.

Lifestyle & Prevention

• Wear supportive footwear and avoid uneven surfaces.
• Use protective gear during high-impact activities.
• Maintain bone health through proper nutrition and exercise.

When to Seek Professional Help

• Severe pain, swelling, or deformity after an injury.
• Inability to bear weight on the foot.
• Open wounds or signs of infection near the heel.

Tips for Medical Coders

• Document the fracture type (e.g., displaced, comminuted) and encounter stage (initial, subsequent) for accurate coding.
• Include details on open vs. closed fractures and any associated injuries to the foot or ankle.
• Ensure clinical documentation supports the specific code assignment for reimbursement and reporting.