S92.03 Avulsion fracture of tuberosity of calcaneus

Name of the Condition

• Avulsion fracture of tuberosity of calcaneus

Summary

This condition involves a fracture where a small piece of bone is pulled away from the tuberosity of the calcaneus (heel bone) due to tendon or ligament tension. It typically results from trauma and can affect mobility and weight-bearing ability, with severity depending on the size of the avulsed fragment.

Causes

High-impact trauma, such as falls or direct force to the heel. Sudden, forceful muscle contractions (e.g., during sports or physical activity) that pull on the attached tendon or ligament.

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, localized pain at the heel or back of the foot.
• Swelling, bruising, or tenderness around the affected area.
• Difficulty or inability to bear weight on the foot.
• Possible visible lump or deformity if the fragment 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 the size and displacement of the avulsed fragment.

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 fragments to realign the bone.

Prognosis and Follow-Up

Healing time varies, typically 4–8 weeks, depending on fracture severity. Follow-up imaging may be used to monitor healing. Physical therapy may be recommended to restore strength and mobility.

Complications

• Nonunion or delayed healing of the avulsed fragment.
• Chronic pain or instability in the heel.
• Nerve or tendon damage from the injury or treatment.

Lifestyle & Prevention

• Wear supportive footwear during physical activity.
• Avoid uneven surfaces or high-impact activities that increase fall risk.
• Maintain bone health through proper nutrition and exercise.

When to Seek Professional Help

Seek immediate medical attention if you experience sudden, severe heel pain after trauma, inability to bear weight, or visible deformity. Persistent pain or swelling after initial treatment also warrants evaluation.

Tips for Medical Coders

Document the specific location (tuberosity of calcaneus) and nature (avulsion) of the fracture. Include details on displacement, treatment, and any associated injuries to ensure accurate coding.