Incision and drainage, leg or ankle; infected bursa
CPT4 code
Name of the Procedure:
Incision and drainage, leg or ankle; infected bursa
Common names: Incision and drainage of an abscessed bursa, I&D of an infected bursa
Summary
Incision and drainage is a minor surgical procedure used to treat an infected bursa in the leg or ankle. The bursa is a small, fluid-filled sac that reduces friction between tissues. When it becomes infected, the area swells and becomes filled with pus. The procedure involves making an incision to drain the infection and relieve symptoms.
Purpose
Medical condition: Bursitis with infection in the leg or ankle
Goals:
- Relieve pain and swelling
- Remove pus and infected material
- Promote healing of the infected bursa
Indications
- Redness, swelling, and pain in the leg or ankle
- Visible or palpable abscess
- Fever and other signs of systemic infection
- Failure to respond to antibiotics alone
Preparation
- Fasting may not be required for this minor procedure.
- Inform the healthcare provider about any medications, especially blood thinners.
- Diagnostic tests like ultrasound or MRI might be needed to assess the extent of the infection.
Procedure Description
- The patient is positioned comfortably, and the affected area is cleaned and sterilized.
- Local anesthesia is administered to numb the area.
- A small incision is made over the infected bursa.
- Pus and infected fluid are drained from the site.
- The wound may be irrigated with saline to ensure all infected material is removed.
- Depending on the severity, a drain might be placed, and the incision is left open or partially closed.
- Sterile dressing is applied to protect the site.
Tools: Scalpel, saline solution, wound dressings
Anesthesia: Local anesthesia
Duration
Typically, the procedure takes about 20 to 40 minutes.
Setting
Performed in an outpatient clinic, hospital, or surgical center.
Personnel
- Surgeon or physician
- Nurse or medical assistant
- Anesthesiologist (if sedation is necessary)
Risks and Complications
- Common risks: Pain, bleeding, infection at the incision site, recurrence of infection
- Rare risks: Deep vein thrombosis, systemic infection (sepsis), damage to surrounding tissues
Benefits
- Immediate relief from pain and pressure
- Reduced risk of further infection or complications
- Improved mobility once the infection resolves
Recovery
- Keep the wound clean and dry as instructed.
- Follow up with the healthcare provider for wound checks and possible removal of any placed drains.
- Complete any prescribed course of antibiotics.
- Full recovery usually takes 1 to 2 weeks, with restrictions on strenuous activities.
Alternatives
- Antibiotic therapy alone (less effective for abscessed bursae)
- Needle aspiration (less invasive but may be insufficient for larger infections)
- Conservative management (only appropriate for non-infected or mildly infected bursitis)
Patient Experience
During the procedure, the patient will feel pressure but should not feel pain due to local anesthesia. After the procedure, discomfort and mild pain at the incision site are normal and can be managed with prescribed pain medication and rest. Follow the care instructions thoroughly to ensure a smooth recovery.