25609-LT ??
DX 813.42

I feel as if I am missing something in this op report??????


Open reduction internal fixation of left distal
radius fracture with fixation of greater than 3 intra-articular fragments.
Instrumentation utilized: Stryker distal radius locking plate.
Anesthesia: General with LMA plus local.
Blood Loss: Less than 50 ml.
Procedure: The patient was taken to the operating room and place supine on
the operating table where general anesthesia was administered and the LMA
was placed. One dose of IV Ancef was administered. Her left arm splint was
removed. The left upper extremity was provisionally cleaned with chlorhexidine
and alcohol. A well-padded tourniquet was applied to the left upper extremity
and the left upper extremity was prepped and draped in the normal sterile
fashion. A time out was taken to confirm that the patient and operative sites
were correct.
An Esmarch dressing was used to exsanguinate the left arm and the tourniquet
was inflated to 250 mmHg. We used a longitudinal incision measuring
approximately 8 to 10 cm in length along the volar aspect of the left wrist directly
over the FCR tendon. Sharp dissection was taken through the skin and
subcutaneous tissues and the sheath over the FCR tendon. The tendon was
then retracted ulnarly and the sheath was incised along its dorsal aspect. The
patient's traumatic injury had essentially torn the pronatus quadratus musculature
from its origin along the volar aspect of the distal radius. With finger dissection
we were able to easily remove this thin shredded muscle belly and gain excellent
visualization of the highly comminuted distal radius fracture.
The fracture edges were freed from interpose muscle belly and soft tissue. The
distal radial styloid piece, which was actually in 2 separate pieces, was
visualized. The brachioradialis tendon was released from the distal most portion
allowing us better mobilization of this fracture fragment.
With direct visualization, we were able to observe from the volar aspect that there
essentially were 3 large intraarticular fracture fragments with one involving the
articular aspect of the radial styloid, the central portion of the distal radius and
then a lunate facet. There was also a large volar cortical piece, which was not
USE CODING GUIDELINES UPDATED SECOND QUARTER 2009 AND CPT 2009
22 of 36 8/29/09
THIS CODING EXAM IS THE PROPERTY OF DUGGAN HIM SERVICES, INC. AND MAY NOT BE REPRODUCED,
SHARED OR DISSEMINATED BY ANY ENTITY OTHER THAN THOSE WITH WHOM A CONTRACTUAL
AGREEMENT IS IN FORCE.
Intraarticular. The lunate facet piece also had a fracture line that extended
proximally to the metadiaphyseal region. Radiographically we also noted that
there was a significant amount of comminution along the dorsal aspect of the
distal radius including the metadiapyseal region.
With direct visualization, we first reduced the central volar, nonarticular cortical
bone fragment. We hel this with a K-wire place from proximal radial to a more
distal ulnar direction. This keyed into position beautifully. With this piece in
place we were then able to reduce the metadiaphyseal portion of the ulnar most
portion of the distal radius. This reduced anatomically as well. This was also
held with a transverse K-wire from radial to ulnar.
After we had reduced these two major fragments we then found that we were
able to use a dental pick and provisionally reduce the remaining intraarticular
fracture fragments back into their anatomic position. We provisionally held these
with K-wire fixation placed transversely. The radial styloid was also reduced and
held with a transverse K-wire placed percutaneously.
We chose a long Stryker volar locking distal radius plate because of the proximal
extension of the fracture. A single screw was placed in the south portion of the
oblong screw hole proximal to the main portion of the fracture. We did not that
there was some dorsal comminution in this region, but the bicortical purchase
was excellent. We then adjusted the plate appropriately so that it lay over the
central portion of the distal radius in a medial to lateral direction and this is was
appropriately positioned with enough purchase distally into the distal comminuted
intraarticular fragments.
After the plate was attached to the diaphyseal region of the distal radius, we then
confirmed reduction of our lunate facet piece. This was confirmed clinically and
radiographically . We then placed 2 locking screws in to the distal most aspect of
the plate along its ulnar side. These locked strongly into the plate. We did note
that there was significant comminution along the dorsal aspect of the distal radius
in this region and the second dorsal cortex was found to be extremely soft in this
region. Therefore, shorter than usual screws were placed.
We next confirmed reduction of our central intraarticular fragment and using this
as a key we were able to anatomically reduce the radial styloid fragment. As
noted, we had provisionally reduced and fixes this with a somewhat transverse
k-wire. We confirmed that the reduction had remained and then went on to this
piece with 2 locking screws into the radial styloid fragment.
A final locking screw was then placed into the central intraarticular fracture
fragment. We again noted that there was significant dorsal comminution and a
relatively short screw was placed in a locking fashion.
USE CODING GUIDELINES UPDATED SECOND QUARTER 2009 AND CPT 2009
23 of 36 8/29/09
THIS CODING EXAM IS THE PROPERTY OF DUGGAN HIM SERVICES, INC. AND MAY NOT BE REPRODUCED,
SHARED OR DISSEMINATED BY ANY ENTITY OTHER THAN THOSE WITH WHOM A CONTRACTUAL
AGREEMENT IS IN FORCE.
We confirmed our reduction. We did note that there was a very small gap
between the radial styloid fragment and the central intraarticular fragment. This
was best seen on a 30 degree oblique view. The AP and lateral views show very
good restoration of the articular surface. We then placed our final 2 shaft screws
proximal to the proximal most extent of the fracture. Excellent purchase was
obtained with both of these nonlocking screws.
At this point, the tourniquet was deflated. No significant bleeding was noted.
Small subcuticular bleeding vessels were cauterized. The pronator quadratus
had been so severely injured that repair of it back to its normal anatomic bed was
impossible. We therefore closed the fascia overlying the FCR tendon with 3-0
Vicryl stitches and closed the deep subcutaneous tissues with 3-0 Vicryl stitches.
The skin was closed using interrupted 3-0 nylon sutures. The single K-wire
which remained in the radial styloid was cut above the skin and bent to greater
than 90 degrees. The provisional K-wires which were originally holding our
metadiaphyseal fracture fragments were removed after placement of the plate[/SIZE]