S92.031 Displaced avulsion fracture of tuberosity of right calcaneus

Name of the Condition

• Displaced avulsion fracture of tuberosity of right calcaneus

Summary

This condition involves a fracture where a fragment of bone is pulled away from the tuberosity of the right calcaneus (heel bone) due to tendon or ligament avulsion. The fracture is displaced, meaning the bone fragment has moved from its original position. It typically results from trauma and can affect weight-bearing ability and mobility.

Causes

High-impact trauma, such as falls from a height or direct force to the heel. Avulsion occurs when a tendon or ligament pulls a piece of bone away from its attachment site, often seen in sports injuries or sudden, forceful movements.

Risk Factors

• Engaging in high-impact activities or sports.
• Osteoporosis or other bone-weakening conditions.
• Improper footwear or uneven surfaces that increase fall risk.
• Previous injuries to the heel or surrounding structures.

Symptoms

• Sudden, severe pain in the heel or back of the foot.
• Swelling, bruising, or tenderness around the heel.
• Difficulty or inability to bear weight on the affected foot.
• Visible deformity if the fracture 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 its displacement and attachment to the tuberosity.

Treatment Options

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

Prognosis and Follow-Up

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

Complications

• Chronic pain or instability in the heel.
• Nonunion or malunion of the fracture.
• Nerve or tendon damage from the injury or surgery.
• Long-term difficulty with weight-bearing activities.

Lifestyle & Prevention

• Wear supportive footwear during high-impact activities.
• Maintain bone health through proper nutrition and exercise.
• Avoid uneven surfaces or hazardous environments that increase fall risk.
• Warm up and stretch before physical activity to reduce injury risk.

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, swelling, or difficulty walking after initial treatment also warrants evaluation.

Tips for Medical Coders

Document the specific location (tuberosity of calcaneus), laterality (right), and fracture type (avulsion, displaced) to ensure accurate coding. Include details on trauma mechanism, imaging findings, and treatment approach to support code specificity.