S92.031A Displaced avulsion fracture of tuberosity of right calcaneus, initial encounter for closed fracture

Name of the Condition

• Displaced avulsion fracture of tuberosity of right calcaneus, initial encounter for closed fracture

Summary

This condition involves a displaced avulsion fracture of the tuberosity of the right calcaneus (heel bone) during the initial encounter for a closed fracture. An avulsion fracture occurs when a fragment of bone is pulled away by a tendon or ligament, and "displaced" indicates the fragment is not in its normal anatomical position. The term "closed fracture" means the skin is intact, with no open wound or exposure of the fracture site.

Causes

High-impact trauma, such as falls from a height or direct force to the heel, is the primary cause. Avulsion fractures often result from sudden, forceful contraction of the Achilles tendon or surrounding ligaments, which can occur during activities like jumping or sudden stops.

Risk Factors

• Engaging in high-impact sports or activities that stress the heel.
• Osteoporosis or other bone-weakening conditions.
• Improper footwear or uneven surfaces that increase fall risk.
• Previous heel injuries or tendon/ligament issues.

Symptoms

• Sudden, sharp 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 significantly 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, evaluate displacement, and rule out other injuries. The "closed fracture" status is determined by the absence of an open wound.

Treatment Options

• Rest and immobilization with a cast or splint to stabilize the bone.
• Pain management with medications or ice therapy.
• Surgical intervention may be required to realign and fix the displaced fragment, especially if it affects function.

Prognosis and Follow-Up

Healing time varies, typically 6–12 weeks, depending on fracture severity and treatment. Follow-up appointments monitor healing progress, mobility, and weight-bearing ability. Physical therapy may be recommended to restore strength and function.

Complications

• Delayed healing or nonunion of the fracture.
• Chronic pain or stiffness in the heel.
• Nerve or tendon damage from the injury or surgery.
• Arthritis in the subtalar joint over time.

Lifestyle & Prevention

• Wear supportive footwear during high-impact activities.
• Strengthen ankle and calf muscles to reduce injury risk.
• Avoid uneven surfaces or hazardous environments 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. Prompt evaluation is critical to assess fracture severity and prevent complications.

Tips for Medical Coders

Document the specific location (tuberosity of calcaneus), laterality (right), displacement status, and encounter type (initial for closed fracture) to ensure accurate coding. Include details on imaging results, treatment provided, and any surgical intervention to support code specificity.