Displaced trimalleolar fracture of left lower leg, sequela

This code indicates a long-term complication or residual effect stemming from a previously sustained trimalleolar fracture of the left lower leg, where the fracture fragments were not in their anatomical position. A trimalleolar fracture involves the lateral malleolus, medial malleolus, and the posterior aspect of the distal tibia (posterior malleolus). The "sequela" designation signifies that the patient is experiencing ongoing issues directly related to the healed or healing fracture, rather than an acute injury.

This code is appropriate when documenting conditions such as chronic pain, nonunion, malunion, post-traumatic arthritis, limited range of motion, or other persistent functional impairments that are a direct consequence of a displaced trimalleolar fracture of the left lower leg that occurred in the past. It should be used after the initial acute phase of treatment has concluded and the patient is being managed for residual effects.

• Always use an additional code to specify the nature of the sequela (e.g., M25.572 for chronic pain, M84.48XA for malunion).
• Ensure documentation clearly links the current condition to the prior displaced trimalleolar fracture of the left lower leg.
• Do not use this code for acute or subacute fracture care; it is exclusively for late effects.