S92.064 Nondisplaced intraarticular fracture of right calcaneus

Name of the Condition

• Nondisplaced intraarticular fracture of right calcaneus

Summary

A nondisplaced intraarticular fracture of the right calcaneus is a break in the right heel bone where the fracture extends into the joint space but the bone fragments remain in their normal alignment. This injury affects the subtalar joint, potentially leading to pain, swelling, and temporary impairment of foot 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.
• Previous heel injuries or surgeries.

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: May be considered if conservative treatment fails or if joint alignment is compromised.

Prognosis and Follow-Up

Most nondisplaced fractures heal well with conservative treatment, but recovery may take several weeks to months. Follow-up imaging and physical therapy are often recommended to monitor healing and restore function.

Complications

• Chronic pain or arthritis in the subtalar joint.
• Difficulty with weight-bearing or mobility.
• Potential for delayed union or nonunion of the fracture.

Lifestyle & Prevention

• Wear appropriate footwear for high-impact activities.
• Use protective gear during sports or work involving fall risks.
• Maintain bone health through diet and exercise to reduce fracture risk.

When to Seek Professional Help

Seek immediate medical attention if severe heel pain, swelling, or inability to bear weight occurs after an injury. Persistent pain or difficulty walking after initial treatment also warrants evaluation.

Tips for Medical Coders

Document the fracture as intraarticular and nondisplaced, specifying the right calcaneus. Include details on imaging findings, treatment approach, and any associated injuries to support accurate coding. Ensure documentation aligns with the clinical presentation and management provided.