Bimalleolar fracture, open

This code describes an open fracture involving both the medial and lateral malleoli of the ankle. An open fracture signifies a break in the skin and underlying soft tissue, exposing the bone to the external environment. This type of injury is typically high-energy and carries an increased risk of infection.

Use this code when documentation clearly states an open fracture of both the medial and lateral malleoli. This diagnosis is supported by operative reports detailing open reduction and internal fixation (ORIF) for an open bimalleolar fracture, or emergency department notes describing an open wound communicating with the fracture site.

• Ensure the documentation explicitly states "open" to differentiate from a closed fracture.
• Do not confuse with trimalleolar fractures, which involve an additional posterior malleolus fracture.
• Always sequence this code as the primary diagnosis when it is the reason for the encounter.