Hello all,
Can anyone please help with this op-report? Open reduction was performed along with percutaneous pinning. Unsure if fracture was extraarticular or intraarticular, and not indicated in X-ray. Or should I just code as percutaneous pinning? 25606/25607/25608? TIA
Postoperative Diagnosis:: Displaced fracture distal left radius.
Procedure(s) Performed:: Open reduction and percutaneous pinning of fractured distal left
radius, application of a bivalve well-padded circular short-arm cast.
Findings:: Dorsally displaced, overriding, radially translated distal left radius fracture
Procedure in Detail: This is a 13-year-old male patient who fell down in a park while playing
soccer, 13 days ago. He fell down and landed on his outstretched left hand and sustained an
overriding dorsally displaced and radially translated transverse fracture of his distal left radius
proximal to the distal growth plate. He had numbness at the palmar aspect of the fingers of the
left hand; progressively the numbness disappeared. Attempts of closed reduction of the
fracture of the distal left radius were done but unsatisfactory. The informed consent was given by his mother
for reduction in the operating room under anesthesia. He was taken to the operating room.
He was placed in supine position on the operating room table. He received general anesthesia.
The procedure was done under image intensifier control as needed. The left upper
extremity was prepped with chlorhexidine solution and the operative site of the left wrist was
draped. Time off was done. This was the correct patient, the correct side, the correct site and
the instruments and implants for the procedure were sterile and available. Under image
intensifier control a 0.062 inch smooth K-wire was percutaneously driven from the tip of the
styloid process of the left radius. The pin went obliquely transfixing the growth plate and
directed towards the ulnar cortex of the distal left radius on AP and anterior views. The pin was
left at the fracture site. A 1 cm skin incision was made on the dorsal aspect of the left wrist at 1
inch proximal to the fracture site. The periosteum was gently freed from the proximal and distal
fragments. The distal fragment was progressively brought over the proximal fragment and
reduced anatomically on AP and lateral views under image intensifier control. The K-wire was
advanced through the fracture site transfixing the ulnar cortex of the distal radius. Control
image intensifier showed anatomical reduction of the fracture of the distal left radius. This was
a transverse fracture and satisfactory fixation with a smooth K-wire. Three stitches of 3-0 nylon
was used to approximate the edges of the skin of the incision. Sterile dressing was applied on
the dorsal wound of the left wrist and around the K-wire. The outer end of the K-wire was bend
in a hook fashion. Sterile dressing was applied on the wounds. A layer of stockinette was
applied from the metacarpophalangeal joints of the fingers up to the elbow. Circularly, layers of
Webril were applied from the metacarpophalangeal joints of the left hand up to the elbow. Circular layers
of fiberglass cast were applied from the metacarpophalangeal joint of the fingers
of the left hand up to the left elbow. The elbow was left free for flexion, extension, and rotation.
Control image intensifier showed anatomical reduction of the transverse fracture of the distal left
radius and satisfactory fixation with a K-wire. The patient tolerated the procedure very well
without complication. He left the operating room in stable condition. He was hemodynamically
stable. He was taken to the recovery room with the Anesthesia and Orthopedic teams.
Evaluated blood loss 20 ml.
Can anyone please help with this op-report? Open reduction was performed along with percutaneous pinning. Unsure if fracture was extraarticular or intraarticular, and not indicated in X-ray. Or should I just code as percutaneous pinning? 25606/25607/25608? TIA
Postoperative Diagnosis:: Displaced fracture distal left radius.
Procedure(s) Performed:: Open reduction and percutaneous pinning of fractured distal left
radius, application of a bivalve well-padded circular short-arm cast.
Findings:: Dorsally displaced, overriding, radially translated distal left radius fracture
Procedure in Detail: This is a 13-year-old male patient who fell down in a park while playing
soccer, 13 days ago. He fell down and landed on his outstretched left hand and sustained an
overriding dorsally displaced and radially translated transverse fracture of his distal left radius
proximal to the distal growth plate. He had numbness at the palmar aspect of the fingers of the
left hand; progressively the numbness disappeared. Attempts of closed reduction of the
fracture of the distal left radius were done but unsatisfactory. The informed consent was given by his mother
for reduction in the operating room under anesthesia. He was taken to the operating room.
He was placed in supine position on the operating room table. He received general anesthesia.
The procedure was done under image intensifier control as needed. The left upper
extremity was prepped with chlorhexidine solution and the operative site of the left wrist was
draped. Time off was done. This was the correct patient, the correct side, the correct site and
the instruments and implants for the procedure were sterile and available. Under image
intensifier control a 0.062 inch smooth K-wire was percutaneously driven from the tip of the
styloid process of the left radius. The pin went obliquely transfixing the growth plate and
directed towards the ulnar cortex of the distal left radius on AP and anterior views. The pin was
left at the fracture site. A 1 cm skin incision was made on the dorsal aspect of the left wrist at 1
inch proximal to the fracture site. The periosteum was gently freed from the proximal and distal
fragments. The distal fragment was progressively brought over the proximal fragment and
reduced anatomically on AP and lateral views under image intensifier control. The K-wire was
advanced through the fracture site transfixing the ulnar cortex of the distal radius. Control
image intensifier showed anatomical reduction of the fracture of the distal left radius. This was
a transverse fracture and satisfactory fixation with a smooth K-wire. Three stitches of 3-0 nylon
was used to approximate the edges of the skin of the incision. Sterile dressing was applied on
the dorsal wound of the left wrist and around the K-wire. The outer end of the K-wire was bend
in a hook fashion. Sterile dressing was applied on the wounds. A layer of stockinette was
applied from the metacarpophalangeal joints of the fingers up to the elbow. Circularly, layers of
Webril were applied from the metacarpophalangeal joints of the left hand up to the elbow. Circular layers
of fiberglass cast were applied from the metacarpophalangeal joint of the fingers
of the left hand up to the left elbow. The elbow was left free for flexion, extension, and rotation.
Control image intensifier showed anatomical reduction of the transverse fracture of the distal left
radius and satisfactory fixation with a K-wire. The patient tolerated the procedure very well
without complication. He left the operating room in stable condition. He was hemodynamically
stable. He was taken to the recovery room with the Anesthesia and Orthopedic teams.
Evaluated blood loss 20 ml.