Name of the Condition

• Unspecified Fracture of Left Calcaneus, Initial Encounter for Open Fracture
• Also known as: Open Heel Fracture

Summary

This condition involves a fracture of the heel bone (calcaneus) on the left foot, with the bone breaking the skin (open fracture). It is identified during the initial medical encounter or treatment stage, meaning it is a new or acute injury.

Causes

• Often caused by high-impact trauma, such as falling from a height, car accidents, or severe sports injuries.

Risk Factors

• Participation in activities with high fall risk (e.g., rock climbing, construction work)
• Osteoporosis or other conditions that weaken bones
• Engaging in high-impact sports

Symptoms

• Severe pain at the heel or back of the foot
• Visible deformity or open wound
• Swelling and bruising
• Difficulty or inability to bear weight on the foot

Diagnosis

• Physical examination for signs of fracture and open wound
• Imaging tests, such as X-rays or CT scans, to confirm fracture details and severity

Treatment Options

• Surgical intervention to clean the open fracture and repair the bone
• Antibiotics to prevent infection due to the open wound
• Pain management with medications
• Immobilization through casting or splinting to aid healing

Prognosis and Follow-Up

• Fracture healing can take weeks to months, depending on severity
• Regular follow-up visits to monitor healing progress and detect complications
• Physical therapy may be needed to restore function and strength

Complications

• Infection due to open fracture
• Nonunion or improper healing of the fracture
• Potential for chronic pain or mobility issues

Lifestyle & Prevention

• Wearing appropriate footwear for activities to reduce injury risk
• Strengthening exercises to improve balance and bone health
• Prompt treatment of any foot or bone conditions

When to Seek Professional Help

• Immediate medical attention if a fracture is suspected, especially with visible bone or open wounds
• Signs of infection, such as increased redness, swelling, or fever

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS) www.aaos.org
• National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center www.niams.nih.gov

Tips for Medical Coders

• Ensure documentation specifies "open" fracture and "initial encounter"
• Avoid confusion with closed fractures or those of other foot bones
• Confirm appropriate use of external cause codes if applicable (e.g., fall, vehicular accident)