Practice Exercises Assignment Pack 4 11. Scenario 11 PREOPERATIVE DIAGNOSIS Open Colles fracture, left wrist. POSTOPERATIVE DIAGNOSIS Open Colles fracture, left wrist. PRIMARY PROCEDURE OPEN REDUCTION INTERNAL FIXATION LEFT DISTAL 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. PROCEDURE After the attainment of adequate general anesthesia, the left upper extremity was prepped and draped. A skin marker was used to identify 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 fixation was obtained. Rotational alignment appeared to be satisfactory. The wound was irrigated, sutured closed and dressed with Xeroflo, cast padding and Ace wrap. The patient tolerated the procedure well and arrived in the recovery room in good condition. Note: External cause code(s) apply : ICD-10-CM: ICD-10-CM: CPT: : Practice Exercises Assignment Pack 4 11. Scenario 11 PREOPERATIVE DIAGNOSIS Open Colles fracture, left wrist. POSTOPERATIVE DIAGNOSIS Open Colles fracture, left wrist. PRIMARY PROCEDURE OPEN REDUCTION INTERNAL FIXATION LEFT DISTAL 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. PROCEDURE After the attainment of adequate general anesthesia, the left upper extremity was prepped and draped. A skin marker was used to identify 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 fixation was obtained. Rotational alignment appeared to be satisfactory. The wound was irrigated, sutured closed and dressed with Xeroflo, cast padding and Ace wrap. The patient tolerated the procedure well and arrived in the recovery room in good condition. Note: External cause code(s) apply : ICD-10-CM: ICD-10-CM: CPT