Name of the Condition

• Unspecified fracture of right calcaneus, subsequent encounter for fracture with nonunion.
• Medical term: Calcaneal fracture with nonunion.

Summary

• This condition refers to a fracture of the right heel bone (calcaneus) that has not healed properly, even after an initial treatment phase. "Subsequent encounter for fracture with nonunion" indicates that the bone ends have not united as expected during the healing period.

Causes

• Such fractures often result from high-impact trauma, such as falls from a height or automobile accidents.
• Nonunion may occur due to inadequate stabilization, poor blood supply to the area, or infection.

Risk Factors

• Smoking, poor nutrition, advanced age, diabetes, and osteoporosis can increase the risk of fracture nonunion.
• Excessive weight bearing on the affected foot before proper healing can also contribute.

Symptoms

• Persistent pain and swelling in the heel area.
• Inability to bear weight or difficulty walking.

Diagnosis

• A new physical examination by an orthopedic specialist.
• Imaging tests like X-rays or CT scans to assess the bone’s healing status.

Treatment Options

• Non-surgical: Use of bone stimulators or functional bracing to promote healing.
• Surgical: Options such as bone grafting and internal fixation to promote union of the bone.
• Pain management with medications as required.

Prognosis and Follow-Up

• Healing can be delayed but is possible with appropriate treatment.
• Follow-up appointments to monitor progress and adjust treatment as needed are crucial.

Complications

• Chronic pain and deformity.
• Reduced mobility or difficulty performing daily activities.
• Potential for arthritis due to joint involvement.

Lifestyle & Prevention

• Cessation of smoking and maintaining a healthy diet to improve healing capability.
• Avoiding high-impact activities until full recovery is confirmed.

When to Seek Professional Help

• Persistent pain despite initial treatment.
• Signs of infection such as redness, warmth, or discharge.
• New or worsening symptoms during recovery.

Additional Resources

• American Orthopaedic Foot & Ankle Society (AOFAS) for patient education.
• Orthopedic or podiatric surgeons specializing in foot and ankle injuries.

Tips for Medical Coders

• Ensure that the encounter is coded appropriately as a subsequent encounter with nonunion.
• Distinguish between initial and subsequent encounters to avoid errors in coding.
• Keep abreast of any updates to the ICD-10 coding for more precise documentation.