Distal Radius ORIF (Volar Plate)
2560725608wRVU: 10.79 — Alternative primary — open treatment distal radial intra-articular fracture, 2 articular fragments (10.79 wRVU, 90-day global) — mutually exclusive with 25607/25609; select one based on fragment count25609wRVU: 14.02 — Alternative primary — open treatment distal radial intra-articular fracture, 3 or more articular fragments (14.02 wRVU, 90-day global) — mutually exclusive with 25607/2560825652wRVU: 7.86 — Open treatment ulnar styloid fracture (7.86 wRVU, 90-day global) — separately reportable alongside 25607/25608/25609 when open ulnar styloid fixation is performed as distinct work; requires modifier 59/XS
Right [left] distal radius fracture, [intra-articular / extra-articular] [/ dorsally angulated / comminuted / with ulnar styloid fracture]
Same
Right [left] distal radius open reduction and internal fixation, volar locking plate
[Attending name], MD/DO
[Resident/PA name]
Regional [WALANT / Bier block / axillary block] [/ general]
The patient is a [age]-year-old [male/female] who sustained a right [left] distal radius fracture after [fall on outstretched hand / high-energy trauma]. Radiographs demonstrate [dorsal angulation / articular comminution / radial shortening / ulnar variance] meeting criteria for surgical fixation. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The distal radius fracture was [intra-articular / extra-articular] with [dorsal / volar] comminution. Pre-operative measurements: radial inclination [X°], volar tilt [−X°] (dorsal), radial height [X] mm, ulnar variance [+X] mm. Post-reduction: radial inclination [X°], volar tilt [+X°], radial height [X] mm. The median nerve was [intact pre-operatively / with acute carpal tunnel syndrome requiring release].
The patient was positioned supine with the arm on a hand table. A forearm tourniquet was applied. The volar forearm was prepped and draped.
A [4]-cm volar longitudinal incision was made in the FCR tendon sheath. The FCR tendon was retracted [ulnarly]. The volar radial sheath was incised and the pronator quadratus was elevated off the volar radial border with electrocautery. The fracture was exposed.
Under fluoroscopic guidance, the fracture was reduced with traction and volarly directed pressure. [A K-wire was used for provisional fixation.] Reduction was confirmed on AP and lateral fluoroscopic views: volar tilt [+10°], radial height [X] mm, radial inclination [X°], articular step-off [<2 mm].
A [Variable Angle LCP / Aptus / DVR Anatomic] volar locking plate was positioned on the volar radial surface, [X] mm proximal to the watershed line. The plate was secured with a shaft screw, and position was confirmed fluoroscopically. Locked distal screws were placed under fluoroscopic guidance confirming sub-articular position without intra-articular penetration on AP, lateral, and [45°] oblique views.
[The pronator quadratus was repaired over the plate with 2-0 Vicryl / The pronator quadratus was allowed to retract — repair is surgeon preference; randomized data do not demonstrate functional benefit from PQ repair.] The FCR sheath was closed. Skin was closed with [3-0 Monocryl].
None
None
Minimal (tourniquet)
None
The patient was placed in a volar splint with the wrist in neutral. Finger range of motion was initiated immediately. Weight-bearing on the operative arm was restricted. Follow-up in [2 weeks] for wound check and splint change to removable brace.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left distal radius fracture, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left distal radius ORIF, volar locking plate
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with distal radius fracture, ***. Criteria for fixation met. Consent obtained.
FINDINGS: *** fracture. Pre-op: volar tilt ***°, radial height *** mm, inclination ***°. Post-reduction: volar tilt +***°, height *** mm. Median nerve ***.
PROCEDURE:
Supine, hand table. Forearm tourniquet. FCR approach. PQ elevated off volar radius. Fracture exposed. Reduced under fluoro; AP/lateral confirmed. Provisional K-wire. *** volar plate positioned *** mm proximal to watershed line. Shaft screw, position confirmed. Locked distal screws; sub-articular, no intra-articular penetration on AP/lateral/oblique. [PQ repaired over plate with 2-0 Vicryl / PQ allowed to retract]. FCR closed. Skin closed. Volar splint.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Volar splint, neutral wrist. Finger ROM immediately. Follow-up 2 weeks.
Signed: .ME, .MYDEGREE
.TODAYVariants
Concomitant Carpal Tunnel Release
Pre-operatively, the patient had acute carpal tunnel syndrome with [median nerve paresthesias / thenar wasting / positive Phalen]. Carpal tunnel release was performed through extension of the volar incision. The transverse carpal ligament was divided under direct vision from proximal to distal, protecting the recurrent motor branch of the median nerve. The median nerve was decompressed and confirmed with a nerve stimulator. Carpal tunnel release was performed prior to fracture fixation to allow median nerve decompression before tourniquet deflation.
Bridging External Fixation (Highly Comminuted / Open Fracture)
Given highly comminuted intra-articular injury [/ open fracture / severe soft tissue compromise], bridging external fixation was applied as a staged procedure or definitive treatment. [2] pins were placed in the second metacarpal and [2] pins in the radial shaft. The frame was assembled with distraction to restore radial length via ligamentotaxis. [Limited internal fixation of articular fragments was performed percutaneously.] Definitive ORIF will be performed [if soft tissues permit, at 7–10 days].
Charting Tips
- Document distal screw position relative to the watershed line. Plates placed distal to the watershed line have direct tendon contact with the flexor tendons, causing rupture (most commonly FPL). Document plate position using the Soong grading system: grade 0 (plate proximal to watershed), grade 1 (plate at or just distal to watershed), grade 2 (plate prominent distal to watershed). Soong grade 2 carries OR 24.9 for FPL rupture. Document that lateral fluoroscopy confirmed sub-watershed placement.
- Document the sky-line (tangential) or tilt view confirming no dorsal screw penetration. Locked distal screws that are too long will penetrate the dorsal cortex and cause extensor tendon rupture (EPL most common). Document the confirmatory fluoroscopic view used.
- Record post-reduction radiographic measurements (volar tilt, radial height, radial inclination, ulnar variance). These parameters define the adequacy of reduction and serve as the baseline for post-operative comparison if malunion is later suspected.
Billing Tips
- Select a single primary code based on articular involvement: 25607 (extra-articular fracture, 9.32 wRVU, 90-day global), 25608 (intra-articular, 2 articular fragments, 10.79 wRVU), or 25609 (intra-articular, 3 or more articular fragments, 14.02 wRVU). These are mutually exclusive — bill one. The code is defined by articular fragment count, not implant type; volar locking plate is used for all three.
- Document the number of articular fragments on preoperative CT and intraoperative assessment, as this is the key billing determinant. Confirm fragment count aligns with the CPT selected.
- Ulnar styloid fixation: the open distal radius codes (25607/25608/25609) do NOT include treatment of the ulnar styloid in their descriptors. When open ulnar styloid fixation is performed as distinct work, CPT 25652 (open treatment ulnar styloid fracture, 7.86 wRVU) is separately reportable with modifier 59/XS. Document the ulnar styloid fracture, instability or displacement, and the distinct fixation technique. Note: closed treatment codes (25600/25605) do include ulnar styloid in their descriptors and are not analogous.
- 90-day global period: cast or splint management, occupational therapy referral, and routine X-ray checks are bundled. Hardware removal for symptomatic implants at a later date is separately billable (CPT 20680, deep implant removal).
- Document neurovascular exam pre- and postoperatively, fracture classification using AO/OTA (preferred; Frykman classification is outdated and no longer recommended in current literature), and all implants placed (plate brand, size, screw lengths and positions, UDI/lot number).
General coding reference. Verify with your institution’s billing department before submitting claims.