S99.091K Other physeal fracture of right calcaneus, subsequent encounter for fracture with nonunion

ICD10CM code

#### Name of the Condition
- Other physeal fracture of right calcaneus, subsequent encounter with nonunion
- *Physis fracture of the right heel bone without healing*

#### Summary
- This condition describes a fracture specific to the growth plate (physis) of the right heel bone (calcaneus) that has not properly healed, known as "nonunion," during a follow-up medical encounter. 

#### Causes
- Trauma or injury to the right heel, often due to falls, sports injuries, or accidents, can cause this type of fracture.
- Inadequate initial treatment or severe fracture complexity may contribute to nonunion.

#### Risk Factors
- Adolescents or individuals experiencing growth spurts, as their growth plates are more vulnerable.
- High-impact sports or activities that put stress on the heel.
- Previous injuries or conditions affecting bone health, like osteoporosis.

#### Symptoms
- Persistent pain or swelling in the heel area.
- Limited range of motion or difficulty bearing weight on the affected foot.
- Visible deformity or bruising.

#### Diagnosis
- Physical examination focusing on the heel.
- Imaging tests such as X-rays or MRI to assess fracture healing and presence of nonunion.

#### Treatment Options
- Immobilization using casts or braces to support the area.
- Surgical intervention may be necessary to promote healing, which can include bone grafting or fixation techniques.
- Physical therapy to improve strength and flexibility after treatment.

#### Prognosis and Follow-Up
- Prognosis varies based on the severity and treatment effectiveness; with proper care, most fractures achieve healing.
- Regular follow-ups are essential to monitor recovery and intervene if healing is not progressing as expected.

#### Complications
- Chronic pain or persistent discomfort.
- Potential for arthritis development in the affected area.
- Impaired function or movement leading to altered activity levels.

#### Lifestyle & Prevention
- Wearing appropriate footwear for activities to provide adequate support and protection.
- Engaging in activities that promote overall bone health, such as weight-bearing exercises and a calcium-rich diet.
- Early intervention and proper management of initial fractures to prevent nonunion.

#### When to Seek Professional Help
- Seek immediate medical attention for severe pain, inability to move the heel, or signs of infection such as fever or redness.
- If previously treated fractures show symptoms like pain or swelling.

#### Additional Resources
- American Orthopaedic Foot & Ankle Society (AOFAS): [www.aofas.org](https://www.aofas.org)
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): [www.niams.nih.gov](https://www.niams.nih.gov)

#### Tips for Medical Coders
- Ensure accurate coding by confirming the fracture site as the right calcaneus and the encounter type as a subsequent visit with nonunion.
- Common coding errors include omitting the specificity of "nonunion" or the involvement of the "right" calcaneus. Double-check these elements for accurate data entry.

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