0.5% Marcaine with epinephrine was injected.
Colles fracture right wrist icd 10 skin#
Using biplane image intensifiers, the skin incision sites were marked. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. General anesthesia was used.) in a supine position. PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia(The type of anesthesia utilized is documented within the report. Most of the softness was in the back part of the vertebral body. At surgery, L2 had some scalloping of the superior end plate. The repeat MRI two weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalloping of the superior end plate, consistent with a compression fracture at L2.(The diagnosis is confirmed in the body of the report.) After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. She initially had very good results, but then developed back pain once again. POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.) NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.) FINDINGS PREOPERATIVELY: She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. What are the CPT® and ICD-10-CM codes reported?ĬASE 2 PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture. The patient was taken to recovery in stable condition. A sterile dressing and sling were applied. The skin was closed with vicryl over a drain and staples in the epidermis. This gave excellent closure and coverage of the significant motion at the repair sites.
These are not reported separately.) The tuberosities were tied down with a suture previously positioned. A matrix is provided where new bone can grow and further stabilize the prosthesis. A bone graft was placed around the area where the tuberosities were being brought down.(Bone grafts are common in prosthetic placement. Once the cement was hardened, the head was placed on Morse taper and then reduced. The shaft was prepared and cement was injected into the shaft. Sutures down to and through the shaft were placed in key positions for closure of the tuberosities.
Colles fracture right wrist icd 10 trial#
Once this was done, the stem was prepared up to a size 10.(This further explains the comminuted fracture.) A trial reduction was carried out with the DePuy trial stem and implant head.(Placement of the prosthesis is described.) This gave good range of motion with good stability. The fragments were mobilized and the humeral head fragments were removed. Dissection was carried out down to the fracture site and the fracture was identified. Standard deltopectoral approach was used.(The approach is documented within the body of the operative report.) The cephalic vein was taken laterally with the deltoid. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where she was prepped and draped in the usual sterile fashion in beach chair position after administering general anesthesia. She stated that she understood and desired to proceed. The proximal end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were discussed. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introduced into the joint.) INDICATIONS: The patient is a 66 year-old female who sustained a traumatic severe comminuted proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture.
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