JOGelico
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Can someone please assist me in coding from this operative report? 
Many thanks!
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed on the table in supine position. General anesthesia was performed. No complications.
The supraclavicular block was given and Propofol anesthesia with light sedation. The patient was placed in the lateral decubitus position. Bean bag inflated. Axillary roll was placed for protection, and the left upper extremity was sterilely prepped and draped in normal sterile fashion. A well-padded tourniquet was placed on the left upper arm and elevated to 275 mmHg. At this point after sterile prep and drape, a 4-cm incision was made centered over the tip of the olecranon-triceps attachment, laterally based to stay away from the median nerve.
Incision was created a 15 blade, and using a Metzenbaum scissor, the top of the olecranon was visualized. There was a very thick bursal sac over the triceps tendon which was excised. The triceps tendon as its insertion had a rent in it, and this was probed and palpated, and there was a little ossicle easily felt detached representing a partial tear of the triceps attachment with a fleck of bone.
A midline incision was made right at the region o the triceps insertion into the olecranon, and immediately encountered was this avulsion fleck. It was a large fleck of approximately 1 cm and was shelled out through this incision. The attachment of the triceps was left intact and essentially the piece was shelled out leaving the triceps tendon intact. When the lesion was shelled out, the fractured ossicle was removed as a specimen. There was a lot of thickening of the triceps underneath. With a Metzenbaum scissor, the thickened portion of the triceps was debrided down to a normal tendon.
The patient had additional spurring of the olecranon extending distally, and a rongeur was used to smooth out this olecranon spur, and the rongeur and rasp were used to completely remove and smooth out the olecranon. At this point, the rent in the triceps tear was then reattached using multiple interrupted #2 Ethibond burying the knot. Five sutures were used for side-to-side closure of the triceps rupture creating a triceps repair.
Many thanks!
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed on the table in supine position. General anesthesia was performed. No complications.
The supraclavicular block was given and Propofol anesthesia with light sedation. The patient was placed in the lateral decubitus position. Bean bag inflated. Axillary roll was placed for protection, and the left upper extremity was sterilely prepped and draped in normal sterile fashion. A well-padded tourniquet was placed on the left upper arm and elevated to 275 mmHg. At this point after sterile prep and drape, a 4-cm incision was made centered over the tip of the olecranon-triceps attachment, laterally based to stay away from the median nerve.
Incision was created a 15 blade, and using a Metzenbaum scissor, the top of the olecranon was visualized. There was a very thick bursal sac over the triceps tendon which was excised. The triceps tendon as its insertion had a rent in it, and this was probed and palpated, and there was a little ossicle easily felt detached representing a partial tear of the triceps attachment with a fleck of bone.
A midline incision was made right at the region o the triceps insertion into the olecranon, and immediately encountered was this avulsion fleck. It was a large fleck of approximately 1 cm and was shelled out through this incision. The attachment of the triceps was left intact and essentially the piece was shelled out leaving the triceps tendon intact. When the lesion was shelled out, the fractured ossicle was removed as a specimen. There was a lot of thickening of the triceps underneath. With a Metzenbaum scissor, the thickened portion of the triceps was debrided down to a normal tendon.
The patient had additional spurring of the olecranon extending distally, and a rongeur was used to smooth out this olecranon spur, and the rongeur and rasp were used to completely remove and smooth out the olecranon. At this point, the rent in the triceps tear was then reattached using multiple interrupted #2 Ethibond burying the knot. Five sutures were used for side-to-side closure of the triceps rupture creating a triceps repair.