11. Scenario 11 PREOPERATIVE DIAGNOSIS
Open Calle fracture left wrist
2
POSTOPERATIVE DIAGNOSIS
Open Colles fracture left wrist.
PRIMARY PROCEDURE
OPEN REDUCTION INTERNAL FIXATION LEFT OISTAL RADIUS FRACTURE WITH DEBRIDEMENT OF OPEN FRACTURE
SITE
BRIEF HISTORY
This 59-year-old female presents with an open Colles fracture of the left wrist due to an automobile accident. The
patient was a passenger in the vehicle that was struck by another vehicle. It was determined that closed
treatment was insufficient for fracture treatment.
350
1
PROCEDURE
After the attainment of adequate general anesthesia, the left upper extremity was prepped and draped. A skin
marker was used to dentify the appropriate location using the position on the forearm for the radius pins. The
fracture and open wound were addressed. The wound required significant debridement of the skin and
subcutaneous tissue prior to proceeding with the repair of the fracture. After adequate debridement the
fracture was reduced to the appropriate anatomic position. Excellent stable foration was obtained Rotational
alignment appeared to be satisfactory. The wound was irrigated, suured closed and dressed with Xerotto, cast
padding and Ace wrap. The patient tolerated the procedure well and arrived in the recovery room in good
condition
M25.46
Note External cause code(s) apply
ICD-10-CM
ICD-10-CM
CPT