Question Monteggia Fracture - Coding Help

cclarson

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Hello everyone, I need some help with how to code the open reduction of the left radiocapitellar joint. The report is below, any help would be deeply appreciated.

Codes I was going to use:
24685 x 2
64718
24635? For Reduction?

POSTOPERATIVE DIAGNOSIS:
Left Monteggia fracture.

OPERATIONS PERFORMED:
1. Open reduction and internal fixation, left coronoid fracture.
2. Open reduction and internal fixation, left olecranon fracture.
3. Open reduction, left radiocapitellar joint.
4. Subcutaneous transposition of the ulnar nerve.

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. Once the block was in place, the patient was transported to the OR in the supine position where she underwent induction of general anesthesia on the gurney. LMA was placed, and the bed was rotated to allow better access to the left upper extremity. Hand table was attached to the left side of the gurney, and the patient underwent prep and drape. After prep and drape, time-out was performed. After routine time-out, we proceeded with the procedure.

I applied a sterile tourniquet and exsanguinated the extremity with an Esmarch bandage. The tourniquet was inflated to 250 mmHg. I then made a posterior incision overlying the olecranon curving my incision medially not placed the incision directly over the olecranon process. Sharp dissection through the skin was followed by elevation of full-thickness skin flaps. I elevated full-thickness skin flaps off the extensor mechanism and off the olecranon. I exposed the olecranon fracture and removed the fracture hematoma. I mobilized the olecranon fracture, exposing the joint. I removed any osteochondral fragments and fracture fragments from the joint. I irrigated the wound thoroughly. I isolated the ulnar nerve by using careful blunt dissection with tenotomy scissors and mobilized the nerve and transposed it subcutaneously. I attempted to reduce the coronoid fracture by approaching it through a medial approach. I elevated the musculature off the ulnar aspect of the olecranon. I was able to visualize the comminuted fracture of the olecranon, which I attempted several times to reduce with some difficulty and recurrent dislocation of the joint due to the large olecranon processes, which contained greater than 90% of the articular surface within the proximal fragment.

At this time, I decided to stabilize the olecranon fracture. I reduced the radiocapitellar joint manually under direct visualization. I reduced the olecranon process fracture, which contained near the entirety of the joint surface and selected a posterior plate from the Acumed tray. I secured the longer plate in position using cortical screw through one of the sliding holes. I checked my positioning on fluoroscopy and found the reduction of the fracture to be acceptable as well as the placement of the hardware, improved my placement of the plate by drilling one of the screw holes within the shaft of the plate eccentrically compressing the plate down further onto the olecranon. I adjusted the positioning of the olecranon fragment by placing a Lobster-claw bone holding forceps onto the olecranon reducing any ulnar or radial offset of the fragment. I then placed K-wires through the drill guide and into the olecranon fragment. Fluoroscopy confirmed extraarticular positioning of the K-wires and appropriate reduction of the fracture as well as appropriate positioning of the plate. I proceeded to place locking screws in the proximal portion of the plate using the block drill guide. After securing the proximal fragment in anatomic position by placing multiple locking screws, I then secured the fracture by placing locking screws within the shaft of the plate.

I turned my attention next to the coronoid process. Range of motion of the elbow showed the elbow to still be unstable without fixation of the coronoid process. I reduced the radial head and ulnar carpal joint, which had dislocated on attempted range of motion. I again irrigated the wound and then continued with dissection around the ulnar aspect of the ulna to approach the olecranon fragments. I flexed the elbow to help reduce the olecranon fragments and continued to release soft tissue off the coronoid fragments to allow for better reduction. I placed a coronoid plate from the Acumed tray onto the anterior aspect of the olecranon trapping the large coronoid fragment in a reduced position. I secured the plate with several cortical screws through the plate to compress the plate down onto the olecranon. There was good restoration of fairly normal articular congruency. The elbow was stable through a range of motion. I irrigated the wound thoroughly and closed the fascia of the flexor pronator mass using Vicryl sutures and closed the deep layer of the incision using Vicryl sutures after again irrigating the wound. Prior to closure of the deep layer, I made a fascial sling and secured the ulnar nerve within the fascial sling beneath the subcutaneous tissue and then closed the deep layer of the incision with Vicryl followed by staples for the skin. I washed the extremity and applied dressings of Xeroform, sterile 4x4s, sterile Webril, and a posterior splint of fiberglass overwrapped with an Ace bandage with the elbow flexed slightly past 90 degrees. The patient was then awakened, extubated, and taken to the recovery room. She arrived in the recovery room in stable condition still under the influence of general sedation. All counts were correct x2.

Thank you!
 
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