S92.035 Nondisplaced avulsion fracture of tuberosity of left calcaneus

Name of the Condition

• Nondisplaced avulsion fracture of tuberosity of left calcaneus

Summary

This condition involves a fracture where a small piece of bone is pulled away from the tuberosity of the left 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 if the fragment is large or unstable (rare for nondisplaced cases).
• Physical therapy to restore strength and mobility after healing.

Prognosis and Follow-Up

Most nondisplaced avulsion fractures heal well with conservative treatment. Full recovery may take several weeks to months, depending on the size of the fragment and adherence to treatment. Follow-up imaging may be used to monitor healing, and physical therapy is often recommended to restore function.

Complications

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

Lifestyle & Prevention

• Wear supportive footwear during high-impact activities.
• Strengthen foot and ankle muscles to improve stability.
• Avoid uneven surfaces or activities with high fall risk.
• Maintain bone health through proper nutrition and exercise.

When to Seek Professional Help

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

Tips for Medical Coders

Document the specific location (left calcaneus) and displacement status (nondisplaced) to ensure accurate coding. Include details about the mechanism of injury, imaging findings, and treatment plan to support code specificity. Verify that the fracture is avulsion-related and not a different type of calcaneal fracture.