S92.062A Displaced intraarticular fracture of left calcaneus, initial encounter for closed fracture

Name of the Condition

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

Summary

A displaced intraarticular fracture of the left calcaneus is a break in the left heel bone where the bone fragments are misaligned and the fracture extends into the joint space. This is a closed fracture, meaning the skin remains intact, and it represents the initial encounter for this injury. The fracture can disrupt joint alignment and function, leading to pain and impaired mobility.

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 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, especially with weight-bearing.
• Swelling and bruising around the ankle and heel.
• Difficulty or inability to bear 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 and evaluate joint involvement and alignment.

Treatment Options

• Conservative management: Rest, ice, compression, elevation (RICE), and immobilization with a cast or boot.
• Surgical intervention: Open reduction and internal fixation (ORIF) may be required for displaced fractures to restore joint alignment.

Prognosis and Follow-Up

Recovery depends on fracture severity and treatment. Immobilization and physical therapy are often needed. Follow-up imaging and clinical evaluations monitor healing and joint function. Long-term outcomes may include persistent pain or arthritis if joint alignment is not restored.

Complications

• Post-traumatic arthritis of the subtalar joint.
• Chronic pain or stiffness.
• Nerve injury or compartment syndrome.
• Nonunion or malunion of the fracture.

Lifestyle & Prevention

• Wear supportive footwear and use protective gear during high-risk activities.
• Maintain bone health through adequate calcium and vitamin D intake.
• Avoid uneven surfaces and use fall-prevention strategies in high-risk environments.

When to Seek Professional Help

Seek immediate medical attention for severe heel pain, inability to bear weight, or visible deformity after trauma. Persistent pain, swelling, or difficulty walking after initial treatment also warrants evaluation.

Tips for Medical Coders

Document the side (left), displacement, intraarticular involvement, and that this is the initial encounter for a closed fracture. Ensure clinical notes specify fracture details, treatment provided, and any complications to support accurate coding.