Orthopedic Coding Alert

"An open reduction and internal fixation of the left distal tibia was done with a medial Synthesperiarticular plate. Under general anesthesia, a tourniquet was placed at the proximal aspect of the left leg and the left leg was prepped and draped in a sterile manner. The limb was exsanguinated and the tourniquet was inflated to 300 mmHg. A medial distal malleolar incision approximately 2 inches in length was performed and taken down to the subcutaneous layer. Bleeding was controlled withelectrocautery. Blunt dissection was carried down to the periosteum which was splint longitudinally in line with the incision. A subperiosteal dissection of the tibia heading proximally crossing the fracture site into the proximal medial tibia was performed. The fracture was then reduced utilizing standard reduction techniques. The plate was then passed and was measured radiographically to its appropriate length. Upon fracture reduction, a K-wire was placed through 2 separate holes in the plate percutaneous holding a temporary fixation. Three distal locking screws and then 3 proximal locking screws including 1 cortical compression screw were placed to hold the fracture in place. It was checked in 3 views to be appropriately positioned in adequate alignment. There was no intraarticular extension of the distal screws into the distal tibiotalar joint. There was comminution at the fracture site but it was compacted within the fracture region. The proximal fibular fracture was stable and showed no evidence or need for fixation. It was not in or including the distal or proximal tib-fib joint. The separate stab incisions that were utilized for the proximal tibial plate were irrigated and closed with 2-0 Vicryl and staples. The distal incision was closed with 0 Vicryl and staples. A sterile bulky dressing was applied to the wound after the distal foot laceration was copiously irrigated and closed with #2 nylon. The posterior splint was applied and the tourniquet was deflated, and the patient was awakened from anesthesia and transferred to PACU in stable condition."

There was also a 4 cm long laceration on the plantar surface between first and second toes.