lindal
Guest
Please help... If anyone could let me know what would be the best CPT code for the closed reduction and pinning of the scapholunate ligament I would greatly appreciate it.
Thanks
Linda L
Thanks
Linda L
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Wiki Closed reduction and pinning scapholunate ligament
- Thread starter lindal
- Start date
mbort
True Blue
Hi Linda,
Could you please post the desensitized information from the op note for this case?
Thanks
Mary
Could you please post the desensitized information from the op note for this case?
Thanks
Mary
amitjoshi4
Guru
- Messages
- 113
- Best answers
- 0
I agree with mbort. Provide the necessary details about this case to get a more clearer picture.25320 is for open procedure. Your doubt lies in closed reduction and pinning.
Thank You
Thank You
mbussey
New
How do I code closed reduction and pinning of a scapholunate ligament disruption
PROCEDURE IN DETAIL: The patient was correctly identified in the
preoperative holding area by his wrist band. Informed consent was
confirmed. A nerve block was then placed by anesthesia. Please see their
note for full details. He was taken back to the operating room and placed
in the supine position where general endotracheal anesthesia was
administered. The left extremity was removed from the splint, and scrubbed
and cleansed so that there was no dirt or remainder debris from any of this
abrasions. At this point, an Allen test was done, demonstrating that he
did have ulnar dominant flow to the wrist. Additionally, images of the
right wrist were obtained for a comparison to aid in our surgical
reduction. The left upper extremity was then prepped and draped in a
standard sterile fashion after placement of a tourniquet. This was not
inflated for any portion of the case. Immediately prior to incision, a
preoperative pause was held, confirming the correct patient, site, side and
identity, that all implants and equipment were available, and that
antibiotics, as above, had been administered. A modified Henry approach
was made to the wrist, the skin incised sharply directly over the FCR
tendon and carried down to this tendon, taking care to identify any
crossing distal nerve branches, which were carefully protected and
retracted. The FCR tendon sheath was identified and incised. The FCR was
retracted ulnarly and then the floor of the subsheath was incised. At this
point, the FPL was identified and the muscle belly of the FPL was swept
aside to identify the surface of the distal radius. The necessary portion
of the shaft for the plate was exposed as well as the distal fracture line
and fracture fragments. Care was taken not to elevate the carpal
ligaments. At this point, it was seen that he really did have a fairly
complex intraarticular fracture based on the visible fracture lines extending into the metaphysis. The radial styloid piece was relatively
small and quite unstable. At this point, the brachioradialis tendon was
released with careful protection of the radial artery from along both
fragments of the radius. The styloid piece was mobilized but care was taken to maintain the capsular and dorsal soft tissues to preserve blood flow to the fragment. Using a
combination of weighted finger traps, and manipulation with K wires and
joysticks we were able to create a relatively stable reduction with
reasonable articular reduction with limited stepoff and this articular
block was then pinned provisionally. Reduction of the articular block to the radius was
then done and preliminarily held with K wires. Due to the instability of
the fracture and the metaphyseal defect it was very difficult to hold this
reduction with K wires alone given the limited bone purchase in the distal
fragment. An appropriately sized plate was chosen and partially affixed to
bone, and then in a sequential manner the plate was used to build the
distal articular fracture, starting with the ulnar column which had proven
the most stable with reduction. This was affixed with a combination of
cortical screws to bring that portion of the articular block down to the
plate. The radial column was then
re-reduced to try and recreate his radial inclination as anatomically as
possible and improve his articular reduction. This was then held
preliminarily with K wires and further cortical screws were used to affix
this portion to the plate. Two screw holes were left available to try and
capture the radial styloid piece. At this point, the radial styloid piece
was captured with a percutaneous wire. It was used a joystick. It was
positioned as anatomically possible and then held preliminarily in place.
A radial styloid screw was then inserted to capture this, but given the
limited purchase that it had the decision was made to cut this wire
subcutaneously after the end was bent and leave it to stabilize the radial
styloid fragment further until healing. The remainder of the cortical
screws were then placed in the shaft and then sequentially the articular
block screws were exchanged for locking screws. In the metaphyseal defect
approximately 3/4 of a mL of demineralized bone matrix putty was inserted
into the metaphyseal defect prior to replacing the radial cortical wall
and encapsulating this. Once this was done the final fluoroscopic images
confirmed that there was no intraarticular penetration of the joint. The
wound was copiously irrigated with normal saline.
At this point, a dynamic axial loading stress test was done of the
scapholunate ligament. It did appear that there was dynamic instability.
This was also suggested on the lateral radiograph by his increased
scapholunate angle. This injury had been suspected previously, but was
confirmed on fluoroscopy. At this point, the incision was copiously
irrigated. The previous surgical incision was then closed in an
interrupted fashion with interrupted 3-0 Monocryl to close the deep and
subcutaneous layers, and then interrupted nylon suture to close the skin.
At this point, given his previous paresthesias and that this had been quite
an involved and long injury, we did decide to proceed with the open carpal
tunnel release as I had discussed with him. An incision was made in line with the radial border of the
fourth ray, just radial to the position of hamate, extending for about 2 cm
from the distal wrist crease to Kaplans line. It was carried down sharply
through the palmar fascia, bluntly down to the level of the transverse
carpal ligament, which was identified. This was incised under direct
visualization. Alternatively, the distal aspect of the incision was then
retracted and under direct visualization the distal portion of the carpal
tunnel release was completed with scissors. Again, this was directly
visualized and the median nerve was then seen within the carpal canal.
Similarly, the proximal aspect was retracted and again under direct
visualization with the scissors tips facing the ulnar direction, the
proximal aspect was completed. A blunt Freer elevator was then passed to
assure that there was no remaining transverse carpal fibers and none were
seen, and there was good evidence of decompression. The incision was then
closed with interrupted nylon suture.
At this point, we turned our attention to repair of the scapholunate
dissociation. Given that this was an acute injury, I had discussed both
options with him, including pinning versus direct repair. Given that this
was an acute injury with only dynamic instability of a relatively low grade, it was thought that
pinning was appropriate. Percutaneous guidewires were placed into the
scaphoid and the lunate respectively. All pins in the case were placed
under oscillating power to avoid any damage to traversing nerve branches.
The scapholunate angle was corrected by using these as percutaneous
joysticks to flex the lunate and slightly extend and ulnarly deviate the
scaphoid. Once this was done we did appear to have a reasonable reduction
and then traversing Kirschner wires were placed across the scapholunate
joint and then as well across the scaphoid into the midcarpal bones to hold
this reduction, but allow free motion at the wrist. These wires were then
bent and cut just below the level of the skin. All wires were buried under
the skin to try and decrease the risk of infection since these wires were
in contact with the other aspects of our final hardware construct that was
not intended to be removed. At this point, the distal radioulnar joint was
assessed. There did appear to be instability that was above average.
There was not gross laxity volarly, but even in pronation there was significant
dorsal laxity of the ulnar, both clinically and on fluoroscopy. The joint
was then held in a reduced position and 2 Kirschner wires were placed,
again in an oscillating fashion in a percutaneous manner after the soft tissues were
bluntly spread down to bone, across the radioulnar joint to hold this in
place. Again, these were bent and placed below the level of the skin for
later removal. Once all this was done final fluoroscopic views were
obtained and then a final sterile dressing was placed followed by a spica
splint. The patient was awoken from anesthesia and transferred to the
postanesthesia care unit (PACU) in good condition. The sponge and
instrument counts were correct. No complications were evident.
PROCEDURE IN DETAIL: The patient was correctly identified in the
preoperative holding area by his wrist band. Informed consent was
confirmed. A nerve block was then placed by anesthesia. Please see their
note for full details. He was taken back to the operating room and placed
in the supine position where general endotracheal anesthesia was
administered. The left extremity was removed from the splint, and scrubbed
and cleansed so that there was no dirt or remainder debris from any of this
abrasions. At this point, an Allen test was done, demonstrating that he
did have ulnar dominant flow to the wrist. Additionally, images of the
right wrist were obtained for a comparison to aid in our surgical
reduction. The left upper extremity was then prepped and draped in a
standard sterile fashion after placement of a tourniquet. This was not
inflated for any portion of the case. Immediately prior to incision, a
preoperative pause was held, confirming the correct patient, site, side and
identity, that all implants and equipment were available, and that
antibiotics, as above, had been administered. A modified Henry approach
was made to the wrist, the skin incised sharply directly over the FCR
tendon and carried down to this tendon, taking care to identify any
crossing distal nerve branches, which were carefully protected and
retracted. The FCR tendon sheath was identified and incised. The FCR was
retracted ulnarly and then the floor of the subsheath was incised. At this
point, the FPL was identified and the muscle belly of the FPL was swept
aside to identify the surface of the distal radius. The necessary portion
of the shaft for the plate was exposed as well as the distal fracture line
and fracture fragments. Care was taken not to elevate the carpal
ligaments. At this point, it was seen that he really did have a fairly
complex intraarticular fracture based on the visible fracture lines extending into the metaphysis. The radial styloid piece was relatively
small and quite unstable. At this point, the brachioradialis tendon was
released with careful protection of the radial artery from along both
fragments of the radius. The styloid piece was mobilized but care was taken to maintain the capsular and dorsal soft tissues to preserve blood flow to the fragment. Using a
combination of weighted finger traps, and manipulation with K wires and
joysticks we were able to create a relatively stable reduction with
reasonable articular reduction with limited stepoff and this articular
block was then pinned provisionally. Reduction of the articular block to the radius was
then done and preliminarily held with K wires. Due to the instability of
the fracture and the metaphyseal defect it was very difficult to hold this
reduction with K wires alone given the limited bone purchase in the distal
fragment. An appropriately sized plate was chosen and partially affixed to
bone, and then in a sequential manner the plate was used to build the
distal articular fracture, starting with the ulnar column which had proven
the most stable with reduction. This was affixed with a combination of
cortical screws to bring that portion of the articular block down to the
plate. The radial column was then
re-reduced to try and recreate his radial inclination as anatomically as
possible and improve his articular reduction. This was then held
preliminarily with K wires and further cortical screws were used to affix
this portion to the plate. Two screw holes were left available to try and
capture the radial styloid piece. At this point, the radial styloid piece
was captured with a percutaneous wire. It was used a joystick. It was
positioned as anatomically possible and then held preliminarily in place.
A radial styloid screw was then inserted to capture this, but given the
limited purchase that it had the decision was made to cut this wire
subcutaneously after the end was bent and leave it to stabilize the radial
styloid fragment further until healing. The remainder of the cortical
screws were then placed in the shaft and then sequentially the articular
block screws were exchanged for locking screws. In the metaphyseal defect
approximately 3/4 of a mL of demineralized bone matrix putty was inserted
into the metaphyseal defect prior to replacing the radial cortical wall
and encapsulating this. Once this was done the final fluoroscopic images
confirmed that there was no intraarticular penetration of the joint. The
wound was copiously irrigated with normal saline.
At this point, a dynamic axial loading stress test was done of the
scapholunate ligament. It did appear that there was dynamic instability.
This was also suggested on the lateral radiograph by his increased
scapholunate angle. This injury had been suspected previously, but was
confirmed on fluoroscopy. At this point, the incision was copiously
irrigated. The previous surgical incision was then closed in an
interrupted fashion with interrupted 3-0 Monocryl to close the deep and
subcutaneous layers, and then interrupted nylon suture to close the skin.
At this point, given his previous paresthesias and that this had been quite
an involved and long injury, we did decide to proceed with the open carpal
tunnel release as I had discussed with him. An incision was made in line with the radial border of the
fourth ray, just radial to the position of hamate, extending for about 2 cm
from the distal wrist crease to Kaplans line. It was carried down sharply
through the palmar fascia, bluntly down to the level of the transverse
carpal ligament, which was identified. This was incised under direct
visualization. Alternatively, the distal aspect of the incision was then
retracted and under direct visualization the distal portion of the carpal
tunnel release was completed with scissors. Again, this was directly
visualized and the median nerve was then seen within the carpal canal.
Similarly, the proximal aspect was retracted and again under direct
visualization with the scissors tips facing the ulnar direction, the
proximal aspect was completed. A blunt Freer elevator was then passed to
assure that there was no remaining transverse carpal fibers and none were
seen, and there was good evidence of decompression. The incision was then
closed with interrupted nylon suture.
At this point, we turned our attention to repair of the scapholunate
dissociation. Given that this was an acute injury, I had discussed both
options with him, including pinning versus direct repair. Given that this
was an acute injury with only dynamic instability of a relatively low grade, it was thought that
pinning was appropriate. Percutaneous guidewires were placed into the
scaphoid and the lunate respectively. All pins in the case were placed
under oscillating power to avoid any damage to traversing nerve branches.
The scapholunate angle was corrected by using these as percutaneous
joysticks to flex the lunate and slightly extend and ulnarly deviate the
scaphoid. Once this was done we did appear to have a reasonable reduction
and then traversing Kirschner wires were placed across the scapholunate
joint and then as well across the scaphoid into the midcarpal bones to hold
this reduction, but allow free motion at the wrist. These wires were then
bent and cut just below the level of the skin. All wires were buried under
the skin to try and decrease the risk of infection since these wires were
in contact with the other aspects of our final hardware construct that was
not intended to be removed. At this point, the distal radioulnar joint was
assessed. There did appear to be instability that was above average.
There was not gross laxity volarly, but even in pronation there was significant
dorsal laxity of the ulnar, both clinically and on fluoroscopy. The joint
was then held in a reduced position and 2 Kirschner wires were placed,
again in an oscillating fashion in a percutaneous manner after the soft tissues were
bluntly spread down to bone, across the radioulnar joint to hold this in
place. Again, these were bent and placed below the level of the skin for
later removal. Once all this was done final fluoroscopic views were
obtained and then a final sterile dressing was placed followed by a spica
splint. The patient was awoken from anesthesia and transferred to the
postanesthesia care unit (PACU) in good condition. The sponge and
instrument counts were correct. No complications were evident.
jessieraebaker
Guest
do you ever determine a code for this?