# Malunion proximal phalanx fx; open wrist traction test



## CPC Coder (Mar 22, 2009)

OK I'll admit it, the surgeon has me stumped on this one. Am I missing the forest for the trees? Help!

Post op dx:
Mal-union of proximal phalanx fx, rt index finger
Ankylosis of proximal interphalangeal joint secondary to extensor tendon adhesions

Procedure:
Rt index derotational osteotomy with distal radius bone graft
Extensor tenolysis of proximal interphalangeal joint capsulotomy, rt index finger

Pre-op note: ...sustained a crush injury of his rt hand several months ago, which included fx of the rt long metacarpal and rt index finger proximal phalanx. The proximal phalanx fx of the index finger was treated with closed reduction and pinning and has healed with slight volar angulation as well as a pronation deformity causing scissoring of the index finger with flexion and grasping activities. He also has limited active flexion of the PIP joint secondary to peritendinous adhesions of the extensor and possibility flexor mechanisms.

Op note in detail: After satisfactory general anesthesia...
Initially the rt index finger was approached through a dorsal longitudinal incision beginning at the base of the proximal phalanx and extending to the middle phalanx curving just radial to the PIP joint. The skin was sharply incised down to and through the subcutaneous tissues. Hemostasis was obtained using bipolar cautery. Radial and ulnar skin flaps were elevated exposing the extensor mechanism. With care taken to preserve the central slip insertion, the extensor tendon  was split longitudinally and peritendinous adhesions were released both superior and deep to the extensor tendon using a scalpel, 69 Beaver blade, and tenolysis instruments. The radial and ulnar lateral bands were also freed from peritendinous adhesions. The dorsal periosteum of the proximal phalanx was then incised longitudinally and reflected radially and ulnarly.

The previous fx site was delineated and a small amount of callus about the fx was removed. A six-hole minifragment plate was then fixed proximal to the site of the proposed osteotomy with appropriate length screws. The plate was then removed and a transverse osteotomy was just then made at the previous fx using a microsagittal saw. The plate was reattached to the fragment proximal to the osteotomy and then the rotational deformity of the index finger was corrected. The distal portion of the p late was then temporarily stabilized to the distal osteotomy fragment with appropriate length 2 mm screws and the remaining screws in the proximal fragment also filled. A small angulatory wedge shaped defect in the osteotomy site persisted and, therefore, it was filled with bone graft harvested from the distal radius.

(He then describes the harvesting of that graft.)

The previously harvested bone graft was then placed into the osteotomy site....x-rays taken.

A wrist traction test was then performed with a small 5-6 cm volar incision beginning at the wrist flexion crease and extending proximally just ulnar to the palmaris longus tendon. Dissection was carried through the skin and subcutaneous tissues. The forearm fascia was incised and the flexor tendon to the index finger delineated. Traction testing showed the tendon to be free of adhesions through the palm through the flexor tendon sheath on the volar surface of the finger.

The wound was irrigated...closed...dressed... splinted..recovery room.

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26445
26445-59
26445-59
26546-59

I don't see 26525 although he says he did it.

And for the wrist traction test...25999 with "similar to 25020" for pricing?

Good grief.

Thank you in advance for any help on this one....fingers are not my area of expertise.

Linda CPC, CPC-H


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## mbort (Mar 23, 2009)

yes for the wrist tractions codes.

I also do not see the documentation for 26525.

I agree with the 26546, however I am not so sure about all of the 26445's, I would check the CCI edits.  If it bundles then I wouldnt code them even with a 59.

My two cents
Mary, CPC, COSC


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## CPC Coder (Mar 24, 2009)

*Thank you True Blue!*

Thank you True Blue, I really appreciate your help!

Linda CPC, CPC-H


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