S92.015 Nondisplaced fracture of body of left calcaneus

Name of the Condition

• Nondisplaced fracture of body of left calcaneus

Summary

This condition refers to a break or crack in the body of the left calcaneus (heel bone) where the bone fragments remain in their normal alignment. It typically results from trauma and can impact weight-bearing ability and mobility, with severity varying based on the fracture's nature.

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 (though less common in nondisplaced cases).

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 (less likely for nondisplaced cases).

Prognosis and Follow-Up

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

Complications

• Delayed healing or nonunion.
• Chronic pain or arthritis in the joint.
• Nerve damage or vascular injury (rare).

Lifestyle & Prevention

• Wear appropriate footwear for high-impact activities.
• Maintain bone health through diet and exercise.
• Use caution on uneven surfaces to reduce fall risk.

When to Seek Professional Help

Seek immediate medical attention if you experience severe heel pain after trauma, swelling, or inability to bear weight on the foot.

Tips for Medical Coders

Document the fracture's nondisplaced nature and specify the left calcaneus body. Include details on trauma mechanism, imaging results, and treatment to support code accuracy. Ensure alignment with clinical documentation standards.