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Incision and drainage, shoulder area; infected bursa

CPT4 code

Name of the Procedure:

Incision and Drainage, Shoulder Area; Infected Bursa

Summary

The incision and drainage procedure for an infected bursa in the shoulder involves creating a small cut to drain pus and relieve pressure, reducing infection and pain.

Purpose

This procedure addresses infections in the bursa of the shoulder, a small fluid-filled sac that reduces friction between tissues. The goal is to remove the infected fluid, alleviate pain, and promote healing.

Indications

  • Severe pain and swelling in the shoulder
  • Signs of infection such as redness, warmth, and fever
  • Failure of conservative treatments like antibiotics and rest
  • Imaging studies confirming an infected bursa

Preparation

  • Fasting for a few hours before the procedure
  • Discontinuation of blood-thinning medications as advised by the doctor
  • Pre-procedure assessments, including blood tests and imaging (e.g., ultrasound or MRI)

Procedure Description

  1. The patient is positioned comfortably, often lying down with the shoulder exposed.
  2. The area is cleaned and sterilized.
  3. Local anesthesia is administered to numb the area.
  4. A small incision is made over the bursa.
  5. Pus and infected material are drained, sometimes using a catheter.
  6. The area may be irrigated with a saline solution.
  7. A sterile dressing is applied to the wound.
  8. Stitches may or may not be used, depending on the drainage need.

Duration

The procedure typically takes 30 to 45 minutes.

Setting

Performed in a hospital, outpatient clinic, or surgical center.

Personnel

  • Surgeon or orthopedic specialist
  • Nurses
  • Anesthesiologist (if general anesthesia is needed, though local anesthesia is more common)

Risks and Complications

  • Infection at the incision site
  • Bleeding
  • Recurrence of the infection
  • Scarring
  • Damage to surrounding tissues

Benefits

  • Relief from pain and swelling
  • Removal of infectious material
  • Prevention of further complications
  • Faster recovery compared to conservative management

Recovery

  • Keep the incision area clean and dry.
  • Follow doctor's instructions on wound care.
  • Complete the prescribed course of antibiotics.
  • Avoid strenuous activity until the shoulder has healed.
  • Typically, recovery time is a few weeks with follow-up appointments to monitor healing.

Alternatives

  • Antibiotic therapy alone (less effective for abscesses)
  • Aspiration of the bursa (less invasive but may not be sufficient)

Patient Experience

  • Expect mild discomfort during the injection of local anesthesia.
  • Minimal pain during the procedure due to anesthesia.
  • Post-procedure pain can be managed with prescribed pain relievers.
  • Possible soreness and restrictions in shoulder movement during recovery.

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