cclarson
Guru
I'm not sure what CPT code to use for a metacarpal malunion repair. I've seen both 26546 and 26565 used before, but I want to use the most appropriate one. Can anyone help me understand which is better to use? Thank you in advance! 
Here is the report:
POSTOPERATIVE DIAGNOSIS:
Right small finger metacarpal neck fracture malunion.
OPERATION PERFORMED:
Repair right small finger metacarpal malunion.
DESCRIPTION OF PROCEDURE:
The patient was met in the holding area. The surgical site was marked and confirmed. Questions were answered. The patient underwent placement of a supraclavicular block by anesthesia attending under ultrasound guidance to provide postoperative pain control. The patient is a recovery addict and did not want the pain medications. It was felt he would benefit most from regional block. After placement of his block he was transported to the OR in the supine position on the gurney where he remained. He underwent induction of general anesthesia, followed by placement of a LMA. Once the LMA was secured, the bed was rotated to allow better access to the right upper extremity. Hand table was attached to the right side of the gurney and the extremity was prepped and draped. After prep and drape, timeout was performed. After routine timeout, I exsanguinated the extremity with an Esmarch bandage and inflated the tourniquet to 250 mmHg.
I made a straight longitudinal incision overlying the right small finger metacarpal starting at the MCP joint dorsally extending proximally. Sharp dissection through the skin was followed by blunt dissection. I exposed and protected any superficial neurovascular structures. I then split the space between the extensor tendons and exposed the fracture. Using subperiosteal dissection, also split the joint capsule exposing the joint. The fracture had healed with 100% volar displacement and foreshortening. I attempted to mobilize the fracture manually without any improvement in the fracture. I directly visualized the healed fracture and using small osteotomes I was able to cut through the healed fracture site, also using fluoroscopic guidance.
After freeing up the distal fracture fragment, I reduced the fracture and advanced a guidewire from the ExsoMed metacarpal nail set through the head of the metacarpal and down the intramedullary canal in the center position and the top one third of the head. After passing the guidewire I was able to visualize it in the exiting intramedullary canal in the distal fracture fragment. I then manipulated the distal fracture fragment until the guidewire entered the intramedullary canal of the proximal fracture, reducing the fracture. I then advanced the guidewire under fluoroscopic guidance measured a 45 and used a 40 mm nail. I overdrilled it with the provided cannulated drill holding the finger flexed. I held the fingers flexed to ensure appropriate rotation of the fracture. There was no crossover or malrotation. I overdrilled the wire and then advanced the cannulated metacarpal nail with some mild compression at the fracture site and good purchase. I seated the nail with DC articular surface under direct visualization. I then removed the guidewire. Final images showed good positioning of the fracture and the hardware.
I then irrigated the wound thoroughly. I closed the periosteum using Vicryl. After closure of the periosteum I irrigated the wound again and then repaired the split within the extensor hood, again using a 4-0 Ethibond. The extremity was then washed and I closed the skin using a running 5-0 nylon. I applied dressings of Xeroform, sterile 4x4s, sterile Webril, and an ulnar gutter splint overwrapped with an Ace bandage. The patient was awakened, extubated, and taken to the recovery room. He arrived in the recovery room in stable condition, still under the influence general anesthesia. All counts correct x2.
Here is the report:
POSTOPERATIVE DIAGNOSIS:
Right small finger metacarpal neck fracture malunion.
OPERATION PERFORMED:
Repair right small finger metacarpal malunion.
DESCRIPTION OF PROCEDURE:
The patient was met in the holding area. The surgical site was marked and confirmed. Questions were answered. The patient underwent placement of a supraclavicular block by anesthesia attending under ultrasound guidance to provide postoperative pain control. The patient is a recovery addict and did not want the pain medications. It was felt he would benefit most from regional block. After placement of his block he was transported to the OR in the supine position on the gurney where he remained. He underwent induction of general anesthesia, followed by placement of a LMA. Once the LMA was secured, the bed was rotated to allow better access to the right upper extremity. Hand table was attached to the right side of the gurney and the extremity was prepped and draped. After prep and drape, timeout was performed. After routine timeout, I exsanguinated the extremity with an Esmarch bandage and inflated the tourniquet to 250 mmHg.
I made a straight longitudinal incision overlying the right small finger metacarpal starting at the MCP joint dorsally extending proximally. Sharp dissection through the skin was followed by blunt dissection. I exposed and protected any superficial neurovascular structures. I then split the space between the extensor tendons and exposed the fracture. Using subperiosteal dissection, also split the joint capsule exposing the joint. The fracture had healed with 100% volar displacement and foreshortening. I attempted to mobilize the fracture manually without any improvement in the fracture. I directly visualized the healed fracture and using small osteotomes I was able to cut through the healed fracture site, also using fluoroscopic guidance.
After freeing up the distal fracture fragment, I reduced the fracture and advanced a guidewire from the ExsoMed metacarpal nail set through the head of the metacarpal and down the intramedullary canal in the center position and the top one third of the head. After passing the guidewire I was able to visualize it in the exiting intramedullary canal in the distal fracture fragment. I then manipulated the distal fracture fragment until the guidewire entered the intramedullary canal of the proximal fracture, reducing the fracture. I then advanced the guidewire under fluoroscopic guidance measured a 45 and used a 40 mm nail. I overdrilled it with the provided cannulated drill holding the finger flexed. I held the fingers flexed to ensure appropriate rotation of the fracture. There was no crossover or malrotation. I overdrilled the wire and then advanced the cannulated metacarpal nail with some mild compression at the fracture site and good purchase. I seated the nail with DC articular surface under direct visualization. I then removed the guidewire. Final images showed good positioning of the fracture and the hardware.
I then irrigated the wound thoroughly. I closed the periosteum using Vicryl. After closure of the periosteum I irrigated the wound again and then repaired the split within the extensor hood, again using a 4-0 Ethibond. The extremity was then washed and I closed the skin using a running 5-0 nylon. I applied dressings of Xeroform, sterile 4x4s, sterile Webril, and an ulnar gutter splint overwrapped with an Ace bandage. The patient was awakened, extubated, and taken to the recovery room. He arrived in the recovery room in stable condition, still under the influence general anesthesia. All counts correct x2.