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HPI
A 22-year-old female, right-hand dominant, presented to the ED after being involved in an arm wrestling match where she noticed immediate pain and deformity of her right arm. She denied pain in her other extremities or any numbness or tingling to the right upper extremity. A reduction is performed by the emergency room physician and the patient is placed in a splint and post-reduction films taken.
PMH
There is no relevant past medical history.
PE
A focused physical examination of the right upper extremity showed obvious deformity with bony crepitus just proximal to the elbow without any open wounds. She had good pulses and a normal capillary refill. The compartments were soft and compressible. A careful exam of the median, ulnar, and radial nerve showed normal function and no deficits.
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Open Reduction Internal Fixation Right Humerus with Posterior approach (CPT 24515)