Fracture of medial malleolus, closed

This code signifies a break in the bony prominence on the inner side of the ankle, specifically the distal tibia, without an open wound communicating with the fracture site. It represents an acute injury to the medial malleolus, often resulting from trauma or twisting forces.

Apply this code for documented closed fractures of the medial malleolus. Supporting documentation should clearly state "closed fracture," "medial malleolus," and the mechanism of injury if available. This code is appropriate for initial encounters and subsequent care for this specific injury.

• Ensure documentation explicitly states "closed" to differentiate from open fractures.
• Do not confuse with fractures of the lateral or posterior malleolus; these have distinct codes.
• Consider additional codes for associated injuries, such as ligamentous tears or other ankle fractures, if documented.