Find information on Medial Malleolus Fracture diagnosis, including clinical documentation tips, ICD-10 and CPT codes, healthcare guidelines, and treatment protocols. Learn about Weber classification, anatomical location, radiographic findings, and associated injuries like posterior malleolus fracture or bimalleolar fracture. This resource supports accurate medical coding, billing, and optimal patient care for medial malleolus fractures.
Also known as
Fracture of medial malleolus
Fracture of the bony prominence on the inner ankle.
Fracture of lower leg
Fractures involving the tibia, fibula, or ankle.
Fractures of lower leg/ankle
Encompasses all fractures of the lower leg and ankle regions.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the fracture closed?
Yes
Displaced?
No
Displaced?
When to use each related code
| Description |
|---|
| Medial Malleolus Fracture |
| Lateral Malleolus Fracture |
| Bimalleolar Fracture |
Missing or unclear documentation of the affected side (right, left, or bilateral) for accurate coding.
Insufficient documentation describing the fracture type (e.g., displaced, comminuted, open) impacts code selection and reimbursement.
Overlooked or undercoded associated injuries (ligament tears, fibular fractures) can lead to lost revenue and compliance issues.
Q: What are the most effective conservative management strategies for stable, Weber A medial malleolus fractures in adults?
A: Conservative management of stable, Weber A medial malleolus fractures in adults typically focuses on pain control, edema reduction, and protected weight-bearing. Key strategies include immobilization with a cast, brace, or splint for 4-6 weeks, regular RICE therapy (rest, ice, compression, elevation), and early range of motion exercises as tolerated. The weight-bearing status should be determined by fracture stability and patient comfort, often progressing from non-weight-bearing to partial weight-bearing then full weight-bearing as the fracture heals. Regular clinical and radiographic follow-up is essential to monitor healing progress. Consider implementing standardized protocols for pain management and rehabilitation to optimize patient outcomes. Explore how weight-bearing protocols can impact return to function.
Q: How do I differentiate between a medial malleolus fracture and a deltoid ligament injury, and what imaging modalities are best for accurate diagnosis?
A: Differentiating between a medial malleolus fracture and a deltoid ligament injury can be challenging, as both present with medial ankle pain and tenderness. Medial malleolus fractures often present with palpable bony tenderness or deformity, whereas deltoid ligament injuries may manifest with diffuse tenderness along the medial ankle. Weight-bearing radiographs are essential for initial evaluation, and while they effectively visualize fractures, they may not always reveal deltoid ligament injuries. Stress radiographs or MRI are often needed to accurately assess deltoid ligament integrity, especially in suspected high-grade injuries. Explore how dynamic ultrasound can be used in conjunction with other imaging modalities for a comprehensive assessment. Learn more about the Ottawa Ankle Rules and their application in these cases to guide imaging decisions.
Patient presents with complaints of medial ankle pain, swelling, and ecchymosis following a twisting injury mechanism. Onset of symptoms occurred [timeframe] ago during [activity causing injury]. Patient reports [weight-bearing status; e.g., able to bear weight, unable to bear weight, partial weight-bearing]. Physical examination reveals tenderness to palpation over the medial malleolus, with palpable bony irregularity in some cases. Ankle range of motion is limited due to pain. Neurovascular examination of the affected extremity is intact, with palpable dorsalis pedis and posterior tibial pulses. Radiographic imaging of the ankle, specifically AP, lateral, and mortise views, confirms the diagnosis of a medial malleolus fracture. The fracture is classified as [Weber classification; e.g., Weber A, Weber B, Weber C] and described as [fracture description; e.g., displaced, nondisplaced, comminuted, spiral]. Assessment includes medial malleolus fracture, ankle sprain, and pain management. Differential diagnosis considered ankle ligament injury. Treatment plan includes [conservative or surgical management; e.g., immobilization with a short leg cast, open reduction internal fixation (ORIF), closed reduction]. Patient educated on pain management, RICE protocol (rest, ice, compression, elevation), and follow-up care. Referral to orthopedics for definitive management may be necessary. ICD-10 code S82.6 assigned for closed medial malleolus fracture. CPT codes for potential procedures may include [relevant CPT codes depending on treatment; e.g., 27766, 27810]. Return to clinic scheduled in [timeframe] for follow-up evaluation and assessment of fracture healing.