In simple words: A broken lower leg, including the ankle, means one or more bones in that area are fractured. This can happen from a fall, accident, or sports injury.It's usually very painful and might cause swelling and bruising. Doctors diagnose it with X-rays and other imaging tests. Treatment depends on how serious the break is—it could involve a cast, surgery, or both.Recovery usually takes several months.

A fracture of the lower leg, including the ankle, refers to a break or discontinuity in the tibia and fibula (the two long bones), the patella (kneecap), and/or the malleolus (the rounded process on either side of the ankle joint), with or without displacement of the fracture fragments.This injury can result from various causes, including falls, traffic accidents, or sports injuries.Bone thinning and cancer can increase fracture risk, even from minor trauma, especially in the elderly.Clinical presentation includes pain, swelling, tenderness, bruising, difficulty moving the leg, restricted range of motion, deformity, and potential numbness/tingling if nerves or blood vessels are damaged. Diagnosis involves patient history, physical exam, laboratory studies (to assess blood loss, clotting, muscle injury), and imaging (X-rays, CT, MRI, bone scan). Treatment options range from immobilization with casts or splints to surgical reduction and fixation, depending on fracture stability and type. Pain management may involve analgesics and/or NSAIDs.Rehabilitation focuses on restoring flexibility, strength, and range of motion.

Example 1: A 25-year-old male sustains a closed, displaced fracture of the tibia and fibula in a motor vehicle accident. He presents to the emergency department with severe pain, swelling, and deformity of his lower leg.X-rays confirm the fracture. He undergoes open reduction and internal fixation (ORIF) with plate and screw fixation., A 70-year-old female with osteoporosis experiences a fall and sustains a minimally displaced fracture of her ankle. She is treated with a short leg cast and pain medication.She undergoes physical therapy post-immobilization., A 16-year-old athlete suffers an open fracture of the tibia during a soccer game. The bone protrudes through the skin. He is taken to the emergency room, where the wound is cleaned and debrided, the fracture is reduced, and he receives antibiotics to prevent infection. He undergoes ORIF.

Detailed documentation should include the mechanism of injury, precise location and type of fracture (e.g., displaced, comminuted, open, closed), radiographic findings, surgical details (if applicable), and the plan for post-operative care, rehabilitation, and pain management.Documentation must support medical necessity for any procedures or services rendered.

** Consider using additional codes to specify associated injuries (e.g., ligament tears, nerve damage, soft tissue injuries).Accurate coding requires thorough review of medical records and appropriate application of coding guidelines.