S92.064A Nondisplaced intraarticular fracture of right calcaneus, initial encounter for closed fracture

Name of the Condition

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

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 and may cause pain, swelling, and temporary impairment of foot function.

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 there is significant joint involvement.

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

• Post-traumatic arthritis of the subtalar joint.
• Chronic pain or stiffness.
• Nerve damage or vascular injury.
• Delayed union or nonunion of the fracture.

Lifestyle & Prevention

• Wear appropriate footwear for high-impact activities.
• Use protective gear in sports or work environments.
• Maintain bone health through diet and exercise.
• Avoid uneven surfaces or hazardous conditions that increase fall 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 important to confirm the diagnosis and initiate appropriate treatment.

Tips for Medical Coders

Document the fracture as nondisplaced and intraarticular, specify the right calcaneus, and note the initial encounter for a closed fracture. Include details on imaging findings, treatment provided, and any follow-up care to support accurate coding.