Encoder Trauma 2

Code the Following Report

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Code this operative report as if you work in the hospital.

Coding Hint:Two diagnosis codes, two CPT codes, and a modifier are associated with this report.

Procedure Note

PROCEDURE: Repair of extensor tendon and local tissue advancement rearrangement for closure of skin avulsion defect, left hand.

DESCRIPTION OF PROCEDURE: After sterile preparation and draping in the normal fashion, infiltration of local anesthetic, and careful undermining, the tendon laceration was exposed. This was about 90 percent lacerated through with some tendon missing. Since there was a significant portion of tendon missing, it was repaired as if 100 percent of the tendon was lacerated and the residual portion underneath was imbricated upon itself and sutured in place with 6-0 PDS suture. This left a smooth gliding plane with no bulk, to help assure the strength of the repair.

The proper tendon repair was done using a modified Kessler 4-0 Prolene suture and a Bunnell 3-0 nylon suture. A running suture was placed around the tendon using a 6-0 Prolene suture. The tendon sheath was closed.

The patient had a large defect over the MCP joint area, which required a rotation advancement flap closure and the rotation advancement flap was done from the ulnar lateral direction on both sides in order to take tension off the proximal distal portions of the repair. Active and passive range of motion could be done with minimal tension or problems from the avulsed tissue.

The formal tendon repair of the extensor tendon of the hand was done and both local tissue rearrangement and advancement flaps were done with a 15-blade scalpel. Extensive undermining and rotation over the flaps after repairing the tendon sheath was done. The flaps were rotated and sutures were put in place using a layered closure; deep sutures, followed by a skin suture. The local tissue advancement rearrangement defect was approximately 1.5 to 2 square cm.