CASE 8-2 Operative Report, Application of Halo Dr. Almaz applies a cranial halo to stabilize a C1-C2 fracture, as illust

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CASE 8-2
Operative Report, Application of Halo
Dr. Almaz applies a cranial halo to stabilize a C1-C2 fracture, as illustrated in Figures 8-3 and 8-4. This is the initial treatment of the injury. Assign an external cause code to indicate how the accident happened.
LOCATION: Outpatient, Hospital
PATIENT: Ella German
SURGEON: Mohomad Almaz, MD
PREOPERATIVE DIAGNOSIS: Fracture of C1 (first cervical vertebra) and C2 (second cervical vertebra)
POSTOPERATIVE DIAGNOSIS: Fracture of C1 and C2
PROCEDURE PERFORMED: Application of halo
PROCEDURE: The patient’s head was prepped and draped. The halo was applied to the head. Lidocaine was used in the area where the pins enter. We then placed the pins and fitted the patient with the rest of the vest. The patient is comfortable. She can get mobilized with the halo. She is 89 years old. You wonder whether she will ever heal after this fall. We will keep her in the halo for 3 to 4 months and see if she heals properly.
SERVICE CODE(S): _________________________________________
ICD-10-CM DX CODE(S): ___________________________________