Orthopaedic New Injury Note with coding

Clinician Specialty: Paediatric Orthopaedic Surgeon Chief Complaint: Right distal radius fracture. Date of Surgery: 11/15/24: Closed reduction and percutaneous pinning of right distal radius fracture Date of Injury: 11/01/24: Fall onto outstretched right hand. History of Present Illness: Liam O'Connell, a 7-year-old patient, is accompanied by his mother for evaluation of a right distal radius fracture. The mechanism of injury was a fall from a bicycle onto an outstretched right hand while playing in the park. The patient initially sought treatment at St. Elsewhere's Urgent Care where they received a temporary splint. Dr. Sarah Jenkins referred the patient to our office for further evaluation. This is not the patient's first orthopaedic injury. His mother was present and contributed significantly to the historical account. Objective: - Vitals: BP 100/60, HR 85, Temp 37.0°C, RR 18. - Physical examination findings, with emphasis on musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, presence of deformity, swelling, or tenderness, etc. Wrist: Inspection: Obvious swelling and dorsal angulation of the right wrist. Skin intact. Palpation: Tenderness to palpation over the distal radius. No crepitus. Range of Motion: | Examination | Right (°) | Left (°) | |-------------|-----------|----------| | Flexion | 20 (painful)| 70 | | Extension | 15 (painful)| 60 | | Ulnar Dev. | 10 (painful)| 30 | | Radial Dev. | 5 (painful) | 20 | Strength Testing: Limited secondary to pain. Grossly intact in unaffected joints. Joint Stability: Not assessed due to acute injury. - Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant: Motor exam is intact for axillary, radial, median, AIN, PIN, and ulnar nerves. Sensation is intact to light touch in all distributions. The capillary refill is less than two seconds. Imaging: - Investigations with results, including imaging and laboratory tests, etc.: X-rays of the right wrist taken today demonstrate a displaced Salter-Harris type II fracture of the distal radius with dorsal angulation and metaphyseal comminution. - In-office x-rays: I ordered and independently reviewed x-rays in office of the RIGHT WRIST today (final radiologist read is pending at the time of the note). The findings are: Displaced Salter-Harris type II fracture of the distal radius with dorsal angulation. - Prior imaging studies: None. - Outside radiologist interpretation: Radiologist at St. Elsewhere's Urgent Care reported a 'likely distal radius fracture, recommend orthopaedic follow-up'. Assessment & Plan: 1. Right Distal Radius Fracture (Salter-Harris Type II) - Assessment, including the likely diagnosis and rationale based on subjective and objective findings: The patient presents with a displaced Salter-Harris Type II fracture of the right distal radius. This diagnosis is supported by the mechanism of injury (fall onto outstretched hand), acute pain and deformity, and confirmed by in-office X-rays. The displacement warrants surgical intervention to achieve appropriate alignment and prevent future growth disturbances. - Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning: Pre-operative blood work (FBC, U&E) and anaesthetic review. - Surgical treatment planned, detailing the type of surgery, the nature of the surgery, and any techniques mentioned: Closed reduction and percutaneous pinning of the right distal radius under general anaesthesia. The fracture will be reduced manually, and K-wires will be inserted across the fracture site to maintain stability. - Non-surgical treatment options, including physiotherapy, casting or bracing, medications, lifestyle modifications, etc.: Non-surgical management with cast immobilisation was discussed but deemed unsuitable due to the significant displacement and potential for malunion or growth arrest. Pain management will include paracetamol and ibuprofen, to be commenced immediately post-operatively. - Post-operative care plan, covering expected hospital stay, rehabilitation, physiotherapy, pain management, and follow-up appointments: Patient to remain overnight for observation. Cast immobilisation for 4-6 weeks post-surgery. Physiotherapy to commence after cast removal, focusing on range of motion and strengthening. Follow-up appointments scheduled for 1-week post-op for wound check and 6-weeks post-op for K-wire removal and X-ray review. Full recovery is anticipated within 3-4 months. - Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc.: Referral to paediatric physiotherapy for post-cast rehabilitation. Additional Notes: - Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care: The patient's mother was counselled regarding the nature of the Salter-Harris Type II fracture, the rationale for surgical intervention, and the expected surgical procedure. Potential risks such as infection, nerve damage, growth arrest, and re-displacement were discussed. Emphasis was placed on the importance of strict cast care, pain management, and adherence to the physiotherapy regime for optimal outcome. - Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for: Pre-operative instructions include NPO after midnight. Post-operative care instructions include keeping the cast dry and clean, elevating the hand to reduce swelling, and monitoring for signs of infection (e.g., fever, excessive pain, redness, discharge) or neurovascular compromise (e.g., numbness, tingling, excessive swelling, inability to move fingers). Activity restrictions include no sports or heavy lifting for 6-8 weeks post-surgery. - Any specific patient or family concerns addressed during the consultation: Mother expressed concerns about the recovery time impacting Liam's participation in school sports. Reassurance was provided that with proper adherence to the rehabilitation plan, he should make a full return to activity. - "After a discussion of the risks, benefits and alternatives, the family wishes to proceed with surgery" CPT Coding Recommendation: 25607 (Closed treatment of distal radial metaphyseal fracture with percutaneous skeletal fixation, > 7 years of age).