Abstract from Documentation: Refer to Bursa, Knee in the Alphabetic Index. What are the choices?
Preoperative Diagnosis: Vastus medialis oblique tear, left knee
Postoperative Diagnosis: Traumatic bursal tear anterior, left knee
Operative Procedure: Inspection, evacuation of hematoma of bursal tissue, left knee
Indication: The patient is a 15-year-old male who injured his left knee while sliding into base during a baseball game. He developed immediate significant swelling and was unable to weight bear for the first few days. I saw him and felt that he might have injured the vastus medialis muscle. An MRI scan of the knee was obtained which demonstrated what appeared to be torn tissue in that area. He has a palpable gap in the area. He has had otherwise good extensor function. We elected to proceed with surgical inspection of the area and repair of suspected muscle tear.
Description of Procedure: The patient received 1 g of Ancef. He was taken to the operating room and given a general anesthetic. I applied a tourniquet to the left thigh and the left lower extremity was prepared with Betadine gel paint and draped out freely. The leg was exsanguinated with an elastic bandage.
I made a longitudinal incision beginning in the mid portion of the patella and extending proximally 4 inches, and dissected down through fairly thick subcutaneous tissue directly into hematoma. This was evacuated. I then split swollen bursal tissue and determined that the underlying vastus medialis muscle and its quadriceps attachment was intact. Further exploration revealed intact capsular tissues and completely intact patellar tendon and quadriceps tendon structures. The bursal tissue was quite hemorrhagic and thickened. No other treatment was indicated.
The area was irrigated and I then closed the subcutaneous tissues with 2-0 Polysorb and the skin with staples. The incision was dressed with bacitracin ointment, 4x4 gauze, ABD pad, and an Ace wrap followed by a knee immobilizer.
The patient tolerated the procedure well. There were no complications. He was taken to recovery in good condition.
Aspiration, Excision, Incision and Drainage, Injection
CPT Code Assignment:
27301-LT Incision and drainage; deep abscess, bursa or hematoma, thigh or knee region
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