S99.021 Salter-Harris Type II physeal fracture of right calcaneus

Name of the Condition

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

Summary

This condition involves a fracture affecting the growth plate (physis) of the right 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 displacement of the metaphyseal fragment.

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 cause displacement of the bone fragment.

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 displacement of 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 as needed.
• Surgical intervention if significant displacement or instability is present.

Prognosis and Follow-Up

Prognosis depends on the severity of the fracture and adherence to treatment. Regular follow-up appointments are necessary to monitor healing and ensure proper growth. Long-term outcomes are generally favorable with appropriate care, though complications may arise in severe cases.

Complications

• Growth disturbances or limb length discrepancies if healing is impaired.
• Chronic pain or stiffness in the ankle or foot.
• Increased risk of future fractures in the affected area.

Lifestyle & Prevention

• Avoid high-impact activities until cleared by a healthcare provider.
• Use protective footwear during sports or activities to reduce injury risk.
• Maintain overall bone health through proper nutrition and exercise.

When to Seek Professional Help

Seek immediate medical attention if experiencing severe pain, inability to bear weight, visible deformity, or signs of infection (e.g., fever, increased swelling, redness).

Tips for Medical Coders

Document the specific Salter-Harris Type II classification and right-sided involvement of the calcaneus. Ensure clinical notes support the fracture type and laterality to justify code assignment.