Reference no: EM133430657

Assignment:

Evaluate Case Study operative report on page 357 and answer the questions below:

• Determine how many codes are needed to code this case correctly
• Determine the root operation(s) would you report
• Justify your response
• Determine the body part(s) for each code you reported?
• Justify your response as why you picked these body parts

Case Study:

Preoperative Diagnosis: Left distal radius and ulna fractures

Postoperative Diagnosis: Left distal radius and ulna fractures

Operation: Closed reduction and percutaneous pinning of left distal radius fracture and closed reduction of left distal ulna fracture

Operative Indications: The patient is an 11-year-old male who has left distal radius and ulna fractures. He presents for surgical treatment. I previously attempted a closed reduction in the fluoroscopy suite next to the emergency room, and his fracture was difficult to reduce without more significant sedation. He thus presents to the operating room for closed reduction and possible pinning and possible open procedure. The risks, benefits, and potential complications were explained to the parents. They understood these things and wished to proceed with surgery.

Technique: The patient was taken to the operating room and placed supine on the OR table with all of his extremities adequately placed. The splint was removed from the left upper extremity and a closed reduction was performed after the patient was under anesthesia. Both fractures were found to reduce. Fluoroscopy was used to view the fracture in multiplanar fluoroscopy. Given the fracture pattern, I thought it would be appropriate to pin the radius to increase stability. Two K wires were then placed under direct fluoroscopic guidance across the fracture site in the radius. The growth plate was avoided. The fracture and pins were again visualized in multiplanar fluoroscopy, and the fractures and the pins were noted to be in good position. The pins were bent and cut. Final films were obtained. Sterile dressings followed by sugar tong type of splint were then applied.