S99.032 Salter-Harris Type III physeal fracture of left calcaneus

Name of the Condition

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

Summary

This condition involves a fracture of the growth plate (physis) of the left calcaneus (heel bone), classified as Salter-Harris Type III. It is a specific type of injury that occurs in the developing bone structure, typically in children or adolescents, and requires careful evaluation to guide treatment. Type III fractures extend through the growth plate and into the epiphysis (the end of the bone), potentially affecting joint surfaces.

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 extend into the epiphysis.

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 studies, such as X-rays, are typically used to confirm the fracture type and extent. The left calcaneus is specifically evaluated to determine the involvement of the growth plate and epiphysis.

Treatment Options

Treatment depends on the severity and displacement of the fracture. Options may include immobilization with a cast or splint, activity modification, or surgical intervention to realign the bone and stabilize the joint surface. Follow-up imaging ensures proper healing.

Prognosis and Follow-Up

Prognosis varies based on the accuracy of reduction and the extent of joint involvement. Regular follow-up appointments monitor healing and assess for growth disturbances. Long-term outcomes depend on proper alignment and adherence to treatment plans.

Complications

Potential complications include growth plate damage leading to limb length discrepancies or angular deformities, joint stiffness, or arthritis if the fracture affects the joint surface. Infection or nonunion may occur with surgical intervention.

Lifestyle & Prevention

Avoid high-impact activities until cleared by a healthcare provider. Use appropriate footwear and protective gear during sports. Strengthening exercises for the foot and ankle may help prevent future injuries once healed.

When to Seek Professional Help

Seek immediate medical attention for severe pain, inability to bear weight, visible deformity, or signs of infection (e.g., fever, increased swelling, redness). Persistent pain or difficulty walking after initial treatment also warrants evaluation.

Tips for Medical Coders

Document the laterality (left calcaneus) and fracture type (Salter-Harris Type III) clearly. Specify if the fracture is open or closed, and note the encounter type (e.g., initial, subsequent) for accurate coding. Ensure clinical documentation supports the specific anatomical location and fracture characteristics.