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Health, 04.04.2020 07:36 sihamabdalla591

PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist.

POSTOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist.(The postoperative diagnosis is used for coding.)

PROCEDURE: Application of a uniplane fixation and closed reduction of left distal radial fracture under fluoroscopy.(This is the working procedure until the report is read.)

ANESTHESIA: General endotracheal.(General anesthesia used.)

DESCRIPTION OF THE PROCEDURE:

After induction of adequate general anesthesia, the patient's left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius.(The external fixation component of the procedure is further described.) We connected these two pins with clamps, and then under C-arm control, we reduced the fracture.(This supports the closed reduction under fluoroscopy.) All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution(The comminuted aspect of the diagnosis is confirmed.) and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible, and tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications.

What are the CPT® and ICD-10-CM codes reported?

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PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist.
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