Reference no: EM133522193
Operative Report: The following documentation is from the health record of a 12-year-old female patient.
Preoperative Diagnosis: Displaced comminuted fracture of the shaft of the right humerus Postoperative Diagnosis: Same Procedure: Open reduction, internal fixation of fracture of shaft of right humerus
History: The patient is a sixth grader whose class was on a field trip at the local bowling alley.
The patient tripped over an object on the alley and fell sustaining a fracture of the right humerus.
Description: The patient was anesthetized and prepped with Betadine, sterile drapes were applied, and the pneumatic tourniquet was inflated around the arm. An incision was made in the area of the lateral epicondyle, and this was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two planes about 90 degrees. It was possible to manually reduce this quite easily, and the judicious manipulation resulted in an almost anatomic reduction. This was fixed with two pins across the humerus.
These pins were cut off below skin level. The wound was closed with some plain catgut subcutaneously and 5-0 nylon in the skin. Dressings were applied to the patient and tourniquet released.
ICD-10-CM Code (5): _______________________________________________________
(DO code for the External Cause Codes)
ICD-10-PCS Code (1): ______________________________________________________