S99.02 Salter-Harris Type II physeal fracture of calcaneus

Name of the Condition

• Salter-Harris Type II physeal fracture of calcaneus
• Growth plate fracture of the heel bone (Type II)

Summary

This condition involves a fracture affecting the growth plate (physis) of the calcaneus (heel bone), classified as Salter-Harris Type II. It occurs in the developing bone structure, typically in children or adolescents, and requires careful management to support healing and growth. Type II fractures involve a separation of the growth plate with a metaphyseal fragment, distinguishing them from other types.

Causes

Direct trauma or injury to the heel, such as falls, sports-related impacts, or accidents. Sudden force applied to the foot, which can disrupt the growth plate and pull a small piece of the adjacent metaphysis.

Risk Factors

• Age: Children and adolescents, as their growth plates are still developing and more susceptible to injury.
• High-impact activities: Participation in sports like running, jumping, or contact sports.
• Previous injuries: Prior damage to the heel or surrounding structures may increase vulnerability.

Symptoms

• Pain and swelling localized to the heel area.
• Difficulty bearing weight or walking on the affected foot.
• Limited range of motion in the ankle or foot.
• Visible bruising or deformity in severe cases.

Diagnosis

Physical examination to assess pain, swelling, and functional limitations. Imaging tests, such as X-rays or MRI, to evaluate the fracture and growth plate involvement, including the metaphyseal fragment.

Treatment Options

• Immobilization with a cast or brace to stabilize the area and promote healing.
• Pain management with medications or other interventions.
• Surgical intervention if the fracture is displaced or unstable.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture and adherence to treatment. Most heal well with proper care, but follow-up imaging may be needed to monitor growth plate function. Long-term outcomes are generally favorable with appropriate management.

Complications

• Growth disturbances or limb length discrepancies if the growth plate is damaged.
• Chronic pain or stiffness in the heel or ankle.
• Arthritis or other joint issues in severe or untreated cases.

Lifestyle & Prevention

• Use protective footwear during high-impact activities.
• Avoid activities that increase fall risk.
• Maintain bone health with proper nutrition and exercise.

When to Seek Professional Help

Seek care if pain, swelling, or difficulty walking persists after an injury, or if deformity or severe bruising is present.

Tips for Medical Coders

Document the Salter-Harris Type II classification and specify the calcaneus involvement. Include details on fracture displacement, treatment, and any complications to support accurate coding. Ensure clinical documentation aligns with the fracture type and anatomical location.