# only 24305



## ASC CODER (Mar 31, 2010)

outpatient basis reporting medial epicondylar type of complaints, especially with hard and strenuous labor, that had been unrelieved with conservative management such as rest, ice, anti-inflammatories, cortisone injections, and bracing. He is also reporting some acute sensitivities along the ulnar nerve, specifically down into the fourth and fifth fingers. He did have an EMG, which was negative, but continues to report numbness and tingling in the fourth and fifth fingers despite bracing to the left elbow. We talked about the risks, benefits, as well as potential complications of going through a left ulnar nerve transposition, such as infection, nerve, artery, blood vessel damage, decreased sensation along the incision site after surgery, injury to the motor branch of the flexor muscles of the forearm, hematoma collection and drain postoperatively, a splint after surgery were all discussed with the patient. We went over these items again this morning preoperatively before signing the consent form, and initialing the site. The H&P was signed. 


DESCRIPTION OF PROCEDURE:
The patient was taken back to the operating suite after the preoperative antibiotics were administered. The patient was given general inhalation anesthesia, and once the tube was secured in place, we took a verbal time out to confirm that the left elbow was the correct operative site. We prepped and draped out the left elbow in a sterile fashion with the arm table and the tourniquet high on the left upper arm. I marked out the medial epicondyle, and then planned an incision just posterior to this area that was parallel with the distal humerus, and gently curved toward the flexor pronator mass. I carried the incision down through the subcutaneous tissues in line with the skin incision, down to the fascia, covering the nerve with the cubital tunnel. I followed this proximally, and dissected out the fascia over the ulnar nerve. I was then able to release this proximally high up into the mid portion of the arm area with some finger dissection, as well as sharp scissor dissection. I was then able to release the cubital tunnel and use a 1/4" Penrose drain around the nerve to help to release the deep fascia fibers as well. 

Distally, I was able to release the superficial fascial coverings, and then the fascia covering the FCU muscle was also released. The muscle fibers divided gently of the FCU. I took care, especially on the posterior surface, to avoid the motor branches to the FCU. The superficial subcutaneous tissues were cleaned off the fascia on the flexor pronator mass. I was then able to do a Z-lengthening of the fascia. The medial intramuscular septum, using bipolar cautery, was ligated. I then cauterized this plexus of veins as well, and made a small groove where the nerve could be coursed up anterior to the medial epicondyle. I was able to do some flexor pronator lengthening by small snips in the muscle, to help to release some of this muscular tissue. There was an intramuscular septum there that I also released, and distally, as the nerve coursed back down into the FCU origin, I was able to release some of this muscle as well. The nerve was able to lie in this groove nicely, with no evidence of entrapment. I was able to close the fascia over the top of the nerve with a tension free repair, and ability to place my pinky underneath this fascia, as well as slide the nerve proximally and distally through this tunnel without any sign of entrapment. The elbow could fully be passively flexed and extended without entrapment, and the nerve again was freely mobile.

At this point, we injected a 0.25% local around the periphery of the incision. I was able to let the tourniquet down at this point to evaluate for any active bleeders. The bipolar cautery was used on some small superficial skin bleeders, but no active bleeders were appreciated. I did use a small little hemostat proximally in the subcutaneous tissues to make a small stab incision in the skin and pass a 1/4" Penrose drain out through the medial upper arm. I closed the subcutaneous tissues with 3-0 interrupted Vicryl stitches, and 4-0 Monocryl was used to seal the skin. I then used 4-0 running Monocryl with Mastisol and Steri-Strips to close the skin as well. There were no complications occurring during the procedure. I put a Webril 4 x 4 dressing on in a sterile fashion, and then did a posterior arm splint with 10-thickness plaster, and finally over wrapped this with a double 4-inch Ace wrap. We held this in place until it had fully cured, with the forearm in a neutral position.


24305 Lt 354.2


the 67418 is bundled per AAOS??

Commercial ins. I wanted another pair of eyes on this to make sure I wasn't missing something. Please take a look... Im pretty sure this is bundled so I would only report the 24305


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## ASC CODER (Apr 2, 2010)

*24305*

Please look at this and give your expertise opinion.


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