S99.091 Other physeal fracture of right calcaneus

Name of the Condition

• Other physeal fracture of right calcaneus
• Growth plate fracture of the right heel bone

Summary

This condition describes a fracture affecting the growth plate (physis) of the right calcaneus (heel bone). Physeal fractures occur in the developing bone structure, typically in children or adolescents, and require evaluation to ensure proper healing and growth.

Causes

Direct trauma or injury to the right heel, such as falls, sports-related impacts, or accidents. Sudden force applied to the foot, which can disrupt the growth plate.

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 right 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.

Treatment Options

• Immobilization with a cast or brace to stabilize the area and promote healing.
• Surgical intervention may be necessary for severe or displaced fractures, which can include fixation techniques.
• Physical therapy to restore mobility and strength after healing.

Prognosis and Follow-Up

Most physeal fractures heal well with appropriate treatment, but follow-up is essential to monitor growth plate function and ensure no long-term complications. Regular check-ups may be needed to assess healing progress.

Complications

• Growth disturbances or limb length discrepancies if the growth plate is damaged.
• Chronic pain or stiffness in the heel.
• Nonunion or malunion of the fracture in severe cases.

Lifestyle & Prevention

• Wear protective footwear during high-impact activities.
• Avoid activities that increase fall risk.
• Maintain bone health through balanced nutrition and exercise.

When to Seek Professional Help

Seek medical attention if pain is severe, swelling worsens, or weight-bearing becomes impossible. Prompt evaluation is critical to prevent complications.

Tips for Medical Coders

Document the specific location (right calcaneus) and physeal involvement clearly. Ensure trauma details and clinical findings support the diagnosis. Follow coding guidelines for fracture specificity and laterality.