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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
- The patient is positioned comfortably, often lying down with the shoulder exposed.
- The area is cleaned and sterilized.
- Local anesthesia is administered to numb the area.
- A small incision is made over the bursa.
- Pus and infected material are drained, sometimes using a catheter.
- The area may be irrigated with a saline solution.
- A sterile dressing is applied to the wound.
- 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.