Wiki Metacarpal bossing

bostonmom

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I need some guidance with the following op note. Doc is saying he did an osteotomy of the right 3rd metacarpal. But to me it does not sound like it. I even asked him, he replied: It was a metacarpal and I used a mallet and an osteotome to make my cuts. I had to excise the periosteum with the bone so I used adjacent periosteum as a flap coverage

PREOPERATIVE DIAGNOSIS: Deformity of the right hand 3rd metacarpal

The doc selected codes:
CPT CODES:
1. The osteotomy for hand deformity -26565
2. Repair of extensor tendon, hand-26410
3. Advancement flap, hand-14040
4. Tenoglide placement

OPERATIVE TECHNIQUE: The patient was brought into the operating room and placed on the table in a supine position. After the induction of general anesthesia, the right upper extremity was surrounded with a tourniquet and prepped and draped in a sterile surgical manner. The arm was then elevated, exsanguinated of all blood and then the tourniquet was insufflated to 100 mm over systolic blood pressure. Attention was then drawn to the dorsum of the right hand. There is obvious deformity at the base of the 3rd metacarpal with angulation of the metacarpal and volar direction. A 15 blade scalpel used to make a longitudinal incision directly over the metacarpal. Blunt dissection was then used to dissect down to the underlying metacarpal. Fifteen blade scalpel used to make a incision on the periosteum and periosteal elevator was used to elevate the periosteum off of the fracture site itself. This was an old healed fracture. There is obvious deformity with bossing of the base of the 3rd metacarpal and angulation. Using an osteotome the bossing on the posterior aspect of the 3rd metacarpal was removed it in a lump dissection. The tendons that had been crossing over this area were significantly frayed. The extensor tendon for the 3rd metacarpal was frayed extensively. This was excised in the middle using a 15 blade scalpel and the 2 edges were then repaired using interrupted figure-of-eight 3-0 Ethibond suture. This left a very large defect of the underlying bone with no overlying periosteum. The periosteum of the proximal wrist was then freed up using a curvilinear incision with 15 blade scalpel. This was then elevated using a periosteal elevator. This periosteum was borrowed from a section of the wrist that was volar and radial to the area of current dissection. This was then rotated up onto the area of the denuded periosteum where the tendons applied. This was sutured in place using interrupted 3-0 Monocryl sutures. The tendons were then wrapped with Tenoglide. The deep fascia was then reapproximated using interrupted 3-0 Monocryl sutures. The deep dermis was reapproximated using 3-0 Monocryl sutures and the skin was reapproximated using 3-0 Monocryl sutures. The patient was then placed in a volar resting splint.
The patient tolerated the entire procedure quite well and will be taken to the PACU in a stable condition. Instrument and sponge count were correct at the end of the case and I did the entire case
 
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