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Any suggestions on how to code, I am hung up on wanting to use 25607 bt something is telling me no. Op note
REOPERATIVE DIAGNOSIS: Gustilo grade I open fracture of distal left radius and ulna.
POSTOPERATIVE DIAGNOSIS: Gustilo grade I open fracture of distal left radius and ulna.
PROPOSED OPERATION: Irrigation and debridement, open reduction and casting of open distal left radius and ulnar fracture.
OPERATIVE PROCEDURE: Irrigation and debridement, open reduction and casting of open distal left radius and ulnar fracture.
GROSS FINDINGS AND TECHNIQUES
CLINICAL HISTORY: This gentleman came in late last night. He had been out rollerblading and fell backwards. He came in with a bleeding deformed left wrist. X-rays showed he had complete displacement of the radius with shortening and also an ulnar fracture as well. It showed just mild angulation. There was a fair amount of bleeding from volar abrasion. It was therefore felt more than likely this was an open fracture. We did discuss current management for open fractures and the time frame between the fracturing and the surgical debridement, but we felt that only a few hours had passed still warranted because of the amount of displacement to try to reduce these after several hours could be quite difficult. I therefore felt it did warrant taking him to surgery tonight for an irrigation and debridement of the wound and also of the fracture and then proceeding with an open reduction but then cast management for his fracture. Risks and benefits were discussed ahead of time.
OPERATIVE REPORT: The patient was taken to the operating room and placed under a general anesthetic. This allowed us to examine his wrist in more detail. We could see that there was fairly exuberant bleeding from about a 3 mm hole on the volar aspect of his wrist. It was therefore felt more likely this was not indeed an open fracture. We had obviously high suspicions earlier.
He was then prepped and draped in the usual manner. I made an elliptical incision around the open wound. We converted to about a 3 cm wound in the volar aspect of his wrist. We went through the skin and then the dermis. More deeply we just followed essentially a dissection path of the compounding right down to the fracture through the flexor musculature. We could see the flexor tendons, pronator quadratus, but never really saw the median nerve.
We were able to look at the fracture ends. They were quite clean. There was no foreign debris. We then drew about 3.5 liters of antibiotic solution. We then tried to reduce this with longitudinal traction creating the deformity. However, there was still some soft tissue entrapment and this was cleaned out with a Freer and then we were able to apply traction and get the fracture reduced. There was still some periosteum stuck. Ultimately though we were able to pick out periosteum and soft tissue from the fracture site and we were able to get an anatomic reduction. We took great care not to go distal in our dissection and dissection was essentially restricted to the metaphyseal zone and 2 or 3 mm on either side of the fracture. More proximally he had pretty well avulsed all the periosteum for about an inch or two proximal to the fracture.
Once we were able to obtain the anatomic reductions of the radius and ulna we irrigated it out once again.
We then reapproximated our surgical wound with loose interrupted sutures. This was then covered with Adaptic then gauze and then Webril. We then put stockinette on the arm. We first were able to maintain the reduction and put a below elbow cast on. AP and lateral fluoroscopy showed an anatomical reduction on both the radius and ulna.
We then proceeded to flex this elbow to 90 degrees and keeping his arm in the neutral rotation and then proceeded to put on the above elbow portion of the cast with stockinette, Webril and plaster. Once the plaster was hardened it was trimmed and then reinforced with fiberglass.
Any help would really be apprecitated. Thanks Sharon
REOPERATIVE DIAGNOSIS: Gustilo grade I open fracture of distal left radius and ulna. POSTOPERATIVE DIAGNOSIS: Gustilo grade I open fracture of distal left radius and ulna.
PROPOSED OPERATION: Irrigation and debridement, open reduction and casting of open distal left radius and ulnar fracture.
OPERATIVE PROCEDURE: Irrigation and debridement, open reduction and casting of open distal left radius and ulnar fracture.
GROSS FINDINGS AND TECHNIQUES
CLINICAL HISTORY: This gentleman came in late last night. He had been out rollerblading and fell backwards. He came in with a bleeding deformed left wrist. X-rays showed he had complete displacement of the radius with shortening and also an ulnar fracture as well. It showed just mild angulation. There was a fair amount of bleeding from volar abrasion. It was therefore felt more than likely this was an open fracture. We did discuss current management for open fractures and the time frame between the fracturing and the surgical debridement, but we felt that only a few hours had passed still warranted because of the amount of displacement to try to reduce these after several hours could be quite difficult. I therefore felt it did warrant taking him to surgery tonight for an irrigation and debridement of the wound and also of the fracture and then proceeding with an open reduction but then cast management for his fracture. Risks and benefits were discussed ahead of time.
OPERATIVE REPORT: The patient was taken to the operating room and placed under a general anesthetic. This allowed us to examine his wrist in more detail. We could see that there was fairly exuberant bleeding from about a 3 mm hole on the volar aspect of his wrist. It was therefore felt more likely this was not indeed an open fracture. We had obviously high suspicions earlier.
He was then prepped and draped in the usual manner. I made an elliptical incision around the open wound. We converted to about a 3 cm wound in the volar aspect of his wrist. We went through the skin and then the dermis. More deeply we just followed essentially a dissection path of the compounding right down to the fracture through the flexor musculature. We could see the flexor tendons, pronator quadratus, but never really saw the median nerve.
We were able to look at the fracture ends. They were quite clean. There was no foreign debris. We then drew about 3.5 liters of antibiotic solution. We then tried to reduce this with longitudinal traction creating the deformity. However, there was still some soft tissue entrapment and this was cleaned out with a Freer and then we were able to apply traction and get the fracture reduced. There was still some periosteum stuck. Ultimately though we were able to pick out periosteum and soft tissue from the fracture site and we were able to get an anatomic reduction. We took great care not to go distal in our dissection and dissection was essentially restricted to the metaphyseal zone and 2 or 3 mm on either side of the fracture. More proximally he had pretty well avulsed all the periosteum for about an inch or two proximal to the fracture.
Once we were able to obtain the anatomic reductions of the radius and ulna we irrigated it out once again.
We then reapproximated our surgical wound with loose interrupted sutures. This was then covered with Adaptic then gauze and then Webril. We then put stockinette on the arm. We first were able to maintain the reduction and put a below elbow cast on. AP and lateral fluoroscopy showed an anatomical reduction on both the radius and ulna.
We then proceeded to flex this elbow to 90 degrees and keeping his arm in the neutral rotation and then proceeded to put on the above elbow portion of the cast with stockinette, Webril and plaster. Once the plaster was hardened it was trimmed and then reinforced with fiberglass.
Any help would really be apprecitated. Thanks Sharon
