Struck by Car

Chief Complaint:

“I was crossing the street and got hit by a car. My right leg is broken and my left wrist hurts.”

History:

Patient is a 24-year-old male brought to the Emergency Department after being struck by a car while crossing the street. He denies any previous medical diseases or surgical procedures.

Review of Systems, Physical Examination and Tests:

• VSS, Physical Exam is within normal limits with the following exceptions:
• RLE—open fracture of the mid-shaft region of the femur. Wound is approximately 15 cm in length and the bone fragments show injury to bone and periosteum (Gustilo Type IIIB). At least three fragments are visible. No apparent nerve or vascular injuries are noted.
• LUE—skin intact over entire extremity. There is obvious deformity of the wrist, which is painful to palpation. Neurological and vascular exam of the hand is intact.
• X-rays: comminuted mid-shaft fracture of the right femur. There is a transverse fracture of the distal left radius just proximal to the wrist joint with dorsal displacement of the distal fragment (Colles’ fracture). All other x-rays are normal.

Hospital course:

The patient was admitted to the hospital and taken directly to the operating room for initial treatment, including debridement and irrigation of the right open fracture and splinting of the left wrist. On the second hospital day, the patient was again taken to the operating room for definitive treatment of the both fractures by open reduction and internal fixation (ORIF) techniques.

Documentation Tips

• Open comminuted fracture of the right femur, mid-shaft treated by ORIF
• Closed transverse fracture of the distal left radius treated by ORIF
• Injuries caused by vehicle-pedestrian accident

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes