S92.061A Displaced intraarticular fracture of right calcaneus, initial encounter for closed fracture

Name of the Condition

• Displaced intraarticular fracture of right calcaneus, initial encounter for closed fracture

Summary

This condition involves a misaligned fracture of the right calcaneus (heel bone) where the fracture extends into the joint space. It is a closed fracture, meaning the skin remains intact, and it is the initial encounter for this injury. The fracture can disrupt joint function and cause significant pain and mobility limitations.

Causes

High-impact trauma, such as falls from a height or motor vehicle accidents, is a common cause. Direct force to the heel, often seen in sports injuries or workplace accidents, can also result in this type of fracture.

Risk Factors

• Participation in high-impact sports or activities.
• Occupations involving heights or fall risks.
• Osteoporosis or other bone-weakening conditions.
• Uneven surfaces or improper footwear increasing fall risk.

Symptoms

• Severe heel pain.
• Swelling and bruising around the ankle and heel.
• Difficulty bearing weight on the affected foot.
• Possible deformity of the heel.

Diagnosis

Physical examination to assess pain, swelling, and deformity. Imaging tests such as X-rays, CT scans, or MRI to confirm the fracture, evaluate its severity, and assess joint involvement.

Treatment Options

• Conservative management: RICE (rest, ice, compression, elevation), immobilization with casts or boots.
• Surgery: Required for displaced fractures to realign bones (open reduction and internal fixation).
• Rehabilitation: Physical therapy to restore movement and strength.

Prognosis and Follow-Up

Healing time varies, typically 6–12 weeks, depending on fracture severity. Follow-up imaging may be needed to monitor healing. Long-term outcomes depend on fracture alignment and joint involvement.

Complications

• Chronic pain or arthritis in the affected joint.
• Nerve damage or numbness.
• Difficulty with weight-bearing or walking.
• Nonunion or malunion of the fracture.

Lifestyle & Prevention

• Wear supportive footwear during high-impact activities.
• Use fall prevention strategies in high-risk environments.
• Maintain bone health through diet and exercise to reduce fracture risk.

When to Seek Professional Help

Seek immediate medical attention if you experience severe heel pain, swelling, or inability to bear weight after an injury. Prompt evaluation is critical for proper management.

Tips for Medical Coders

Document the side (right), intraarticular involvement, and initial encounter for a closed fracture. Ensure clinical notes specify displacement and joint involvement to support this code.