The patient was taken back to the operating room suite, placed upon the operating table with the right arm extended on the arm table. She was given conscious sedation throughout the procedure, supported with an LMA. We began the procedure by removing her cast on the right upper extremity. We were able to clean her right upper extremity using Hibiclens scrub brush, and I dried it thoroughly before the routine ChloraPrep. We did apply a tourniquet to the right upper arm, and it was inflated for just over an hour, 250 mm/Hg, throughout the procedure. The incision was an FCR incision on the radial aspect of the distal radius, carried down through the skin and subcutaneous tissues, with the tissues divided in line with the incision. We were able to cut down directly onto the FCR tendon. I was able to mobilize the FCR in an ulnar direction and cut through the deep fascia directly onto the pronator quadratus. I was able to mobilize the pronator quadratus in an ulnar direction as well, so as to visualize the shaft of the distal radius and the significant amount of comminution present at the fracture site. There was a significant amount of volar displacement with buckling and prominent callus formation. The fracture was not mobilizable. We had to do a fair amount of osteoclasis in order to loosen up the fracture fragments. The radial styloid was essentially mush, with just soft bone and eggshell fragmentation noted as we were trying to mobilize any of the fragments. I was able to restore some of the length of the distal radius, but the more we mobilized it, the more I felt pieces were just falling apart. The dorsal cortex remained impacted and intact, whereas the volar cortex seemed to mobilize nicely. I used a combination of osteotomes and Freer to help to free up the surrounding soft tissues, and longitudinal traction to help to lengthen the distal radius. I then applied the plate and used the K-wires across the distal portion of the plate. To confirm I was not intraarticular, I then used the oblong hole on the shaft to help me to secure the plate to the bone as well. After this, we used the mini C-arm to confirm our placement, and noted that we did not get an exact restoration of the volar tilt. This was difficult to obtain because of the dorsal comminution that had essentially healed in this comminuted position. I used the osteotomes to try to free up this tissue, but was unable to do so. I felt the more we tried to free up these tissues, the more the bones were falling apart, and I was scared that we were going to eventually get an intraarticular break that would create a more complex fracture than what we had at this point. I did settle for the curved position, which was neutral, but did improve the overall length of her fracture. I did get two screws up into the radial styloid as well, and four screws across the distal radius surface. Three cortical screws were used in the shaft of the bone, and held the plate securely. AP and lateral images confirmed placement of the plate, and there were no complications with this procedure so far.

I got 25607 Rt with 813.42
76496 TC 813.42

patient is Medicare. I have read and researched and it seems that the Dr. has to be specific about fragments. Due to the fact that its stated comminution and he didn't want an intraarticular break that it would only be one fragment that he fixated. (even though he states fracture fragments.) I need some help...