Displaced trimalleolar fracture of right lower leg, sequela

This code signifies a past injury involving a fracture of all three malleoli (medial, lateral, and posterior) in the right lower leg, where the bone fragments were not properly aligned. The "sequela" indicates that this code is used to report a condition that is a residual effect or complication of that original trimalleolar fracture, rather than the acute injury itself.

Use this code when documenting a patient presenting with long-term complications or chronic conditions directly resulting from a previously sustained, displaced trimalleolar fracture of the right lower leg. Examples include chronic pain, nonunion, malunion, post-traumatic arthritis, or persistent instability after the initial healing phase. This code is not for the initial treatment of the acute fracture.

• Always ensure documentation clearly links the current condition to the prior displaced trimalleolar fracture of the right lower leg.
• Do not use this code for the initial encounter or active treatment of the acute fracture; instead, use the appropriate acute fracture code.
• Consider additional codes for specific sequelae, such as M19.171 for post-traumatic osteoarthritis of the right ankle, if documented.