ORIF of left zygomaticomaxillary complex fracture and ORIF lt supraorbital rim fracture

Can someone please help me with this? I do not code Ortho very often.

After proper informed consent was obtained, the patient was taken from the holding area to the operating room, laid in the supine position.  General anesthesia was induced and the patient was intubated via oral RAE.  Corneal Shields were placed and the patient was prepped and draped in usual sterile fashion.  Local anesthetic in the form of lidocaine 1% with 1:100,000 epinephrine was then injected into the proposed incision site at the left lateral orbital rim and left maxillary vestibule.  Adequate time for vasoconstriction and hemostasis was allowed to occur.  A 15 blade was then used to make an incision through the previously closed laceration at the left lateral orbital rim.  Further sharp and blunt dissection were carried out to the lateral orbital rim and the superior rim of the left orbit, subperiosteal dissection was then carried out to expose the fracture sites.  Bovie cautery was then used to make a vestibular incision in the maxillary left vestibule.  Subperiosteal dissection was carried out to expose the zygomaticomaxillary buttress and a completely exposed fracture of the zygomaticomaxillary buttress.  A Seldin elevator and Kocher forceps were then used to reduce the displaced zygomaticomaxillary complex fracture.  A Synthes 2.0 L plate was then anatomically contoured to span the fracture on the zygomaticomaxillary buttress and fixated with appropriate screws.  Attention was then directed to the left lateral orbital rim and superior orbital rim, where the free-floating bony segment was reduced.  A Synthes 1.5 curvilinear plate was then used to reduce and fixate the left lateral orbital rim.  The superior orbital rim was then fixated with a 1.5 X shaped plate and appropriately fixated with fixation screws.  At this time, the wounds were copiously irrigated.  The left lateral orbital rim incision was closed in a layered fashion using 4-0 Vicryl sutures and 5-0 Prolene sutures to approximate the superficial skin; 3-0 chromic gut sutures were used to close the maxillary left vestibular mucosal incision.  At this time, the corneal shields were removed.  A forced duction test was performed and found to be negative and the eyes were irrigated with balanced salt solution.  At this time, the anesthesia was terminated.  The patient was extubated and taken to the PACU in stable and hemostatic condition.

 

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