Alfaro33
Networker
Hello. Would 25024 and 29125 be appropriate? I'm on the fence on the splint code.
Any help would be appreciated.
Preoperative Diagnosis
Left wrist septic arthritis
Postoperative Diagnosis
Left wrist septic arthritis
Operation
Left wrist incision, drainage, and irrigation
Anesthesia
General endotracheal
Technique
Patient was identified in the preoperative holding area. He was given the opportunity to ask any questions and informed consent was obtained. All risks and benefits and alternative treatment options were discussed in detail with the patient. Risks include but not limiting to complications from anesthesia, malunion, nonunion, need for possible additional surgery, DVT, infection, symptomatic hardware, neurovascular injury were discussed in detail. He wished to proceed with the plan. Patient's operative extremity was marked by operative surgeon which concurred with the operative consent. Patient was transferred to the operating room where she was placed on the operative table. Anesthesia was administered via the anesthesia team.
The left upper extremity was prepped and draped in standard orthopedic fashion. An operative time-out was taken by the surgical team and all were in agreement. A 5 cm incision was made on the dorsum of the wrist between the 3rd and 4th extensor compartments. Electrocautery was used to obtain and maintain hemostasis throughout the case. Combination of blunt and sharp dissection was taken down to the wrist capsule. Extensor tendons were carefully retracted for exposure. Multiple pockets of purulence were encountered with dissection down to the wrist capsule. Wrist capsule was sharply incised and purulent fluid was evacuated. Multiple cultures were taken. The joint was thoroughly irrigated with 3 L saline. 1 g of vancomycin powder was placed in the wound. Wrist capsule and extensor retinaculum closed with 2-0 PDS. Subcutaneous tissue was closed with 3-0 PDS. Skin incision was closed with 3-0 nylons. Xeroform, 4x4s, cast padding, volar splint was then applied. All needle and sponge counts were correct x2.
The patient was successfully extubated in the operating room and transferred to PACU in stable condition.
Findings
Purulent fluid in dorsum of wrist and joint
Any help would be appreciated.
Preoperative Diagnosis
Left wrist septic arthritis
Postoperative Diagnosis
Left wrist septic arthritis
Operation
Left wrist incision, drainage, and irrigation
Anesthesia
General endotracheal
Technique
Patient was identified in the preoperative holding area. He was given the opportunity to ask any questions and informed consent was obtained. All risks and benefits and alternative treatment options were discussed in detail with the patient. Risks include but not limiting to complications from anesthesia, malunion, nonunion, need for possible additional surgery, DVT, infection, symptomatic hardware, neurovascular injury were discussed in detail. He wished to proceed with the plan. Patient's operative extremity was marked by operative surgeon which concurred with the operative consent. Patient was transferred to the operating room where she was placed on the operative table. Anesthesia was administered via the anesthesia team.
The left upper extremity was prepped and draped in standard orthopedic fashion. An operative time-out was taken by the surgical team and all were in agreement. A 5 cm incision was made on the dorsum of the wrist between the 3rd and 4th extensor compartments. Electrocautery was used to obtain and maintain hemostasis throughout the case. Combination of blunt and sharp dissection was taken down to the wrist capsule. Extensor tendons were carefully retracted for exposure. Multiple pockets of purulence were encountered with dissection down to the wrist capsule. Wrist capsule was sharply incised and purulent fluid was evacuated. Multiple cultures were taken. The joint was thoroughly irrigated with 3 L saline. 1 g of vancomycin powder was placed in the wound. Wrist capsule and extensor retinaculum closed with 2-0 PDS. Subcutaneous tissue was closed with 3-0 PDS. Skin incision was closed with 3-0 nylons. Xeroform, 4x4s, cast padding, volar splint was then applied. All needle and sponge counts were correct x2.
The patient was successfully extubated in the operating room and transferred to PACU in stable condition.
Findings
Purulent fluid in dorsum of wrist and joint