Not sure if this is the right code 21365.........need help!!
Dx: Left tripod fx with extension to the antral wall
Procedure: Open reduction and internal fixation of a left tripod fracture with extension to the antral wall with miniplate insertion
The head was tilted towards the rt side and a left infraorbital incision was mmade just along the lower most crease of the eye. This was carried down to the deeper layer, transecting the skin, the periorbital muscle and the periosteum. The fracture site was noted, which was displaced. The surgial site was then packed with gauze and then we directed our attention to the left supraorbital area just at the location of the frontotemporal suture lines. In the same way the transection was made through the skin, subcutaneous area and the muscle, and down into the greater ostium. The fractured site was noted and again this was cleansed and the bleeding was controlled with Bovie cauterization. Using a pin blazer the previously incised malar area with a number 10 knife,this was screwed into the malar bone and traction was placed anteriorly and caused a reduction of the displaced zygomatic bone. We went to the previous two incisions and showed that there was a good reduction of the infraorbital suture of the fracture to tthe infraorbital area and also at the fontotemporal area. A six hole plate was then placed at the infraorbital area and a 3 millimeters screw was inserted and this caused a good stabilization. At the frontotemporal area fx a four hole plate was inserted and also anchored in place with the use of a 3 millimeters suture. The gingiva sulcus area at this jucture was incised and the antral wall was inspected. There was a good reduction at this jucture and the previous plan of putting a balloon was abandoned due to the good reduction.
Any help would be appreciated, Cathy
Dx: Left tripod fx with extension to the antral wall
Procedure: Open reduction and internal fixation of a left tripod fracture with extension to the antral wall with miniplate insertion
The head was tilted towards the rt side and a left infraorbital incision was mmade just along the lower most crease of the eye. This was carried down to the deeper layer, transecting the skin, the periorbital muscle and the periosteum. The fracture site was noted, which was displaced. The surgial site was then packed with gauze and then we directed our attention to the left supraorbital area just at the location of the frontotemporal suture lines. In the same way the transection was made through the skin, subcutaneous area and the muscle, and down into the greater ostium. The fractured site was noted and again this was cleansed and the bleeding was controlled with Bovie cauterization. Using a pin blazer the previously incised malar area with a number 10 knife,this was screwed into the malar bone and traction was placed anteriorly and caused a reduction of the displaced zygomatic bone. We went to the previous two incisions and showed that there was a good reduction of the infraorbital suture of the fracture to tthe infraorbital area and also at the fontotemporal area. A six hole plate was then placed at the infraorbital area and a 3 millimeters screw was inserted and this caused a good stabilization. At the frontotemporal area fx a four hole plate was inserted and also anchored in place with the use of a 3 millimeters suture. The gingiva sulcus area at this jucture was incised and the antral wall was inspected. There was a good reduction at this jucture and the previous plan of putting a balloon was abandoned due to the good reduction.
Any help would be appreciated, Cathy
Last edited: