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Thread: Op note distal tibia

  1. #1
    Join Date
    Apr 2007

    Default Op note distal tibia

    AAPC: Back to School
    How would you code this op note?

    PREOPERATIVE DIAGNOSIS: Salter Harris Type II fracture left distal tibia.

    POSTOPERATIVE DIAGNOSIS: Salter Harris Type II fracture left distal tibia.

    PROCEDURE: Closed reduction left distal tibia with percutaneous screw fixation.

    Fluoroscopy was used to visualize the fracture. He was noted to have a posteriorly displaced Salter Harris Type II fracture with the metaphyseal fragment located posteriorly. The fracture was reduced by applying longitudinal traction and counter traction. The traction was applied with the foot in equinus and then the foot was brought up into dorsiflexion as anteriorly directed force was applied to the heel. This resulted in near anatomic position of the fracture.

    A 1cm longitudinal incision was made just lateral to the Achilles' tendon. Blunt dissection was taken down through the subcutaneous tissues down to the posterior tibia. The K-wire guide for the 4.0 cannulated screw was positioned under fluoroscopic control through the metaphyseal fragment and proximal to the physis. The screw was measured. A 30mm 4.0 cancellous screw was placed. Good purchase was obtained on the screw. The position was then again verified fluoroscopically in anterior and posterior, and lateral X-rays were obtained which showed the fracture was anatomically reduced and the screw was in excellent position.

    The stab incision was closed with two interrupted stitches of 3.0 Nylon. A sterile dressing was applied and then the patient was placed in a well padded short leg plaster splint. The procedure was then terminated. The patient was awakened from anesthesia and sent to the recovery room in satisfactory condition. There were no complications.

  2. #2


    Take a look at 27827 and see if that works.
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

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