ahalle
Contributor
So I'm confused on this one. The Doctor is treating patient for the first time but patient has a non-union and a new fracture on the same bone. Debating between 25405 or 25545 for the procedure and whether Dx should be the S52.262A as he lists it or should be split into two seperate Dx for the nonunion and new fracture. I feel like the 25405 is closer to what he did but then I need it to be the non-union dx leading me to think about splitting the diagnosis. Just thought some additional thoughts on this might help me make up my mind.
POSTOPERATIVE DIAGNOSIS: Segmental fracture, left forearm, mid and distal ulna.
INDICATIONS: This patient sustained a fracture of his left proximal ulna, treated surgically
with an open reduction Internal fixation in South Texas. He developed a delayed union and initially was
starting to use a bone growth stimulator when he fell against some stairs at home and sustained a 2nd fracture
at the end of the previously-placed fixation plate. It was recommended that he have a surgical treatment to fix
both fractures and bone graft both fractures.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and under satisfactory
anesthesia in a supine position, given 2 g of Ancef intravenously. Time~out was taken to identify the correct
patient, site, and procedure. The patient was prepped and draped and an Esmarch was used to exsanguinate
the left upper extremity. The tourniquet was inflated at 250 mmHg. A longitudinal incision was made along the
lateral border of the left forearm corresponding to the lateral border of the ulna utilizing the prior surgical scar.
Incision was carried through the skin, subcutaneous tissue, and deep fascia, and periosteum. The bone was
exposed with periosteal elevators and the plate overlying was removed. Two fractures were identified. The
proximal fracture had a nonunion and it was curetted of fibrous tissue. Autograft bone was taken from the
proximal ulna with curettes and packed around the nonunion site. The distal fracture was identified and
reduced and held in place with the holding pin and additional bone graft was packed around that site. The
fractures were then secured with a 14- hole fixation plate from Stryker. Bone clamps were used to hold the
plate to the bone and the plate was sequentially fixed to the bone with multiple blcortical nonlocking screws. X Rays
intraoperatively revealed satisfactory position of the fracture and fixation device.
POSTOPERATIVE DIAGNOSIS: Segmental fracture, left forearm, mid and distal ulna.
INDICATIONS: This patient sustained a fracture of his left proximal ulna, treated surgically
with an open reduction Internal fixation in South Texas. He developed a delayed union and initially was
starting to use a bone growth stimulator when he fell against some stairs at home and sustained a 2nd fracture
at the end of the previously-placed fixation plate. It was recommended that he have a surgical treatment to fix
both fractures and bone graft both fractures.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and under satisfactory
anesthesia in a supine position, given 2 g of Ancef intravenously. Time~out was taken to identify the correct
patient, site, and procedure. The patient was prepped and draped and an Esmarch was used to exsanguinate
the left upper extremity. The tourniquet was inflated at 250 mmHg. A longitudinal incision was made along the
lateral border of the left forearm corresponding to the lateral border of the ulna utilizing the prior surgical scar.
Incision was carried through the skin, subcutaneous tissue, and deep fascia, and periosteum. The bone was
exposed with periosteal elevators and the plate overlying was removed. Two fractures were identified. The
proximal fracture had a nonunion and it was curetted of fibrous tissue. Autograft bone was taken from the
proximal ulna with curettes and packed around the nonunion site. The distal fracture was identified and
reduced and held in place with the holding pin and additional bone graft was packed around that site. The
fractures were then secured with a 14- hole fixation plate from Stryker. Bone clamps were used to hold the
plate to the bone and the plate was sequentially fixed to the bone with multiple blcortical nonlocking screws. X Rays
intraoperatively revealed satisfactory position of the fracture and fixation device.