Fracture of medial malleolus, open

This code signifies an open fracture affecting the medial malleolus, the bony prominence on the inside of the ankle. An open fracture indicates a break in the skin and soft tissue, exposing the bone or allowing communication between the fracture site and the external environment.

Apply this code when documentation clearly states an open fracture of the medial malleolus. This typically occurs following trauma where the skin integrity is compromised at the fracture site. Look for terms like "compound fracture," "open wound communicating with fracture," or descriptions of bone protruding through the skin.

• Differentiate carefully between open and closed fractures; this code is specific to open injuries.
• Ensure documentation specifies the medial malleolus; do not use for fractures of other ankle malleoli.
• Always sequence this code as the primary diagnosis when it is the reason for the encounter.