S92.034 Nondisplaced avulsion fracture of tuberosity of right calcaneus

Name of the Condition

• Nondisplaced avulsion fracture of tuberosity of right calcaneus

Summary

This condition involves a fracture where a small piece of bone is pulled away from the tuberosity of the right calcaneus (heel bone) due to tendon or ligament tension. The fracture is nondisplaced, meaning the bone fragment remains in its original position. 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 may be required if the fragment is large or unstable.

Prognosis and Follow-Up

Most nondisplaced fractures heal with conservative treatment, but recovery time depends on the size of the fragment and adherence to immobilization. Follow-up imaging may be needed to confirm healing. Physical therapy is often recommended to restore strength and mobility.

Complications

• Delayed healing or nonunion if the fragment is large or poorly immobilized.
• Chronic pain or stiffness in the heel.
• Risk of re-injury if activity is resumed too soon.

Lifestyle & Prevention

• Wear supportive footwear during high-impact activities.
• Strengthen lower leg muscles to reduce strain on the heel.
• Avoid uneven surfaces or activities with high fall risk.

When to Seek Professional Help

Seek immediate care if pain is severe, swelling worsens, or weight-bearing becomes impossible. Persistent pain or difficulty walking after initial treatment also warrants evaluation.

Tips for Medical Coders

Document the nondisplaced nature of the fracture and specify the right calcaneus. Include details on trauma mechanism, imaging findings, and treatment approach to support code specificity. Ensure clinical documentation aligns with the avulsion fracture description.