S92.031S Displaced avulsion fracture of tuberosity of right calcaneus, sequela

Name of the Condition

• Displaced avulsion fracture of tuberosity of right calcaneus, sequela

Summary

This condition represents a displaced avulsion fracture of the tuberosity of the right calcaneus (heel bone) during the sequela phase. An avulsion fracture occurs when a tendon or ligament pulls a bone fragment away from its attachment site, and "displaced" indicates the fragment has moved from its original position. The term "sequela" denotes a residual effect or complication following the acute injury, such as chronic pain, limited mobility, or structural changes resulting from the prior fracture.

Causes

The sequela arises from a prior avulsion fracture of the calcaneal tuberosity, typically caused by high-impact trauma (e.g., falls, direct force to the heel) or sudden forceful muscle contractions. The residual effects develop as the body heals, leading to persistent symptoms or anatomical changes.

Risk Factors

• History of prior avulsion fracture of the calcaneal tuberosity.
• Inadequate initial treatment or healing of the acute injury.
• Underlying bone conditions (e.g., osteoporosis) that impair recovery.
• High-impact activities or sports that stress the heel post-injury.

Symptoms

• Chronic pain or discomfort in the heel or back of the foot.
• Persistent swelling, bruising, or tenderness around the affected area.
• Reduced range of motion or stiffness in the ankle/foot.
• Difficulty bearing weight or altered gait due to residual instability.
• Visible or palpable deformity from the displaced fragment.

Diagnosis

Physical examination to assess pain, swelling, and functional limitations. Imaging (e.g., X-rays, CT scans) to evaluate the fracture site, fragment position, and healing status. Clinical history confirming prior avulsion fracture and the transition to sequela.

Treatment Options

Conservative management (rest, physical therapy, orthotics) to improve mobility and reduce pain. Surgical intervention may be considered for severe displacement or functional impairment. Pain management and activity modification are tailored to the individual’s symptoms and recovery progress.

Prognosis and Follow-Up

Prognosis depends on the severity of the initial injury, treatment, and adherence to rehabilitation. Most patients experience improved function with appropriate care, though some may have long-term limitations. Regular follow-up with imaging and clinical assessments monitors healing and adjusts treatment as needed.

Complications

• Chronic pain or arthritis in the subtalar joint.
• Persistent instability or difficulty with weight-bearing.
• Nerve or tendon damage from the displaced fragment.
• Delayed union or nonunion of the fracture site.

Lifestyle & Prevention

• Avoid high-impact activities that stress the heel until cleared by a provider.
• Use supportive footwear or orthotics to reduce strain.
• Engage in low-impact exercises (e.g., swimming, cycling) to maintain mobility.
• Address underlying bone health (e.g., calcium, vitamin D) to support recovery.

When to Seek Professional Help

Seek care if symptoms worsen (e.g., increased pain, swelling, or deformity), or if new issues (e.g., numbness, infection) arise. Prompt evaluation is recommended for significant functional limitations or concerns about healing.

Tips for Medical Coders

Document the sequela phase clearly, including the history of the prior avulsion fracture and current residual effects. Ensure clinical notes specify the anatomical location (right calcaneus tuberosity), displacement status, and the transition to sequela. Code S92.031S is used when the condition represents a residual effect of the initial fracture, not the acute injury.