# Please advise......



## SHIBA425 (Jun 25, 2007)

*I need help with an orthopedic surgery.   Please advise if the following codes are appropriate for the operative note listed:

24579, 25607-51, 64721-51*

PREOPERATIVE DIAGNOSIS: Fractured distal right radius (extraarticular), and
fracture of anterior aspect of trochlea of right elbow.

PROPOSED OPERATION: Open reduction and internal fixation of distal right radius fracture plus open reduction and internal fixation of right trochlea fracture.

POSTOPERATIVE DIAGNOSIS: Fractured distal right radius (extraarticular), and fracture of anterior aspect of trochlea of right elbow.

OPERATIVE PROCEDURE: Open reduction and internal fixation of distal right
radius fracture plus open reduction and internal fixation of right trochlea
fracture; carpal tunnel release, and exploration of ulnar nerve.

GROSS FINDINGS AND TECHNIQUES

This person came in last night. Suffered a fall. Had obvious deformity and fracture to the right wrist. X-rays revealed an extraarticular right radius fracture. He also had a fracture of the elbow. He has pagetoid distal humerus and it was difficult to define the true architecture of the fracture. He had a CT scan and this showed a fracture of the anterior aspect of the trochlea and also involving the anterior aspect of the medial epicondyle. The posterior aspect was intact. It was, therefore, elected to proceed with open reduction and internal fixation of the distal right radius fracture and also open reduction and internal fixation of the trochlear fracture. The risks and benefits of the surgery were discussed.

The patient was taken to the operating room and placed under general
anesthesia. His right arm was prepped and draped in the usual manner. A
tourniquet had been placed around the proximal right arm. An incision was made over the distal right radius. We carried the incision into the palm. *As we got towards the carpal tunnel, it was quite tight. A strand of his carpal ligament was quite thickened. The medial nerve was flattened. It became quite hyperemic once released. *We continued dissection more proximally. We dissected on the ulnar aspect of the flexor carpi radialis.

We then dissected out pronator quadratus. We then took one of the Synthes
precontoured volar plates and in a sequential manner, holes were drilled,
measured, and appropriate-size screws were inserted. On the more distal aspect we used the locking guide for putting in locking screws. We took care to make sure each screw was knotted to the joint. We also inserted locking screws into the distal radius. We locked the plate, all of the screws were tightened down.  The fracture was anatomically reduced. There was no soft tissue entrapment. The pronator quadratus was not in good enough status to repair. We made sure the median nerve was still intact. We irrigated out the wound thoroughly. The subcutaneous tissues and skin were closed in the usual fashion.

*We turned to the elbow*. We demarcated anatomical landmarks and made a medial incision. We dissected sharply down through skin. Bleeders were cauterized. We got down to the posterior medial epicondyle to assess the ulnar nerve, it was intact, and we followed it both distally and proximally. We then proceeded to release some of the common flexor origin off the medial epicondyle and as soon as we did, we got out more distally, and we could see the large trochlear fragment which had migrated proximally, about 1 cm. We evacuated a large hematoma. We were able to get the trochlear fragment reduced. It was held tentatively with K-wires. We took fluoroscopic films for anatomic reduction. We also put a dissecting finger in and we could see where it cross towards the capitellum. It appeared to be anatomically reduced. We could see the coronoid process.

We then proceeded to use the Synthes headless screw fixation system. We
inserted a K-wire and then put in appropriate-sized screw lengths. 

Once we were done, there was good fixation. There was no prominent hardware. I put the elbow through a range of motion and the fracture appeared to be stably reduced. Fluoroscopic films showed anatomic reduction and hardware in good position.

We irrigated out the wound thoroughly. We looked at the ulnar nerve and it was still intact. We used heavy Vicryl to close and repair the flexor origin. We
then closed the subcutaneous tissues and skin in the usual fashion. A posterior splint was applied with the elbow in 90 degrees of flexion to take tension off the flexors.


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## daraustin (Apr 17, 2013)

Codes look good.

If you need to appeal anything...highlight the procedure and place the code next to the highlighted area...I've had positive responses with this from the insurance companies.

Best Wishes,
Darlene Austin, CPC, COSC, Author DOCUMENT SMART, M.D. For Orthopaedic Surgery (darlenecoder@hotmail.com)


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