Trimalleolar fracture, closed

This code signifies a closed fracture involving all three malleoli of the ankle: the medial, lateral, and posterior malleoli. This type of fracture results in significant instability of the ankle joint. "Closed" indicates that the skin over the fracture site remains intact.

Apply this code when documentation clearly states a trimalleolar ankle fracture and specifies that it is a closed injury. This typically occurs following high-energy trauma to the ankle, such as falls or twisting injuries. Supporting documentation includes radiology reports (X-rays, CT scans) confirming the involvement of all three malleoli and physician notes detailing the closed nature of the injury.

• Ensure the documentation explicitly mentions involvement of the posterior malleolus in addition to the medial and lateral malleoli.
• Distinguish carefully between closed and open fractures; an open trimalleolar fracture would require a different code.
• Consider sequencing this code as the primary diagnosis when it is the reason for the encounter, especially for initial treatment.