POSITIVE START Make sure bony prominences are padded and nerves are protected every time you position patients.

Imagine going to see Wonder Woman and not moving once during the 2-hour, 21-minute film. That's right, you'd never cross or uncross your legs or shift your weight from one cheek to the other. Sounds brutally painful, right? That's how your patients would feel on the OR table if they were conscious.

"Pain is protective," says Bradford Tucker, MD, an assistant professor of orthopedic surgery at Thomas Jefferson University and a sports medicine surgeon at the Rothman Institute in Philadelphia, Pa. "When patients are asleep, they don't sense discomfort, so it's the surgical team's responsibility to ensure every body part is positioned with perfect ergonomics in mind and that every bony prominence is well padded, every nerve is free from compression and the neck is neutrally aligned."

Proper patient positioning also gives surgeons the access to joints they need to perform their preferred surgical approaches. Perhaps more importantly, it minimizes patient harm, including the potential for soft tissue injury, nerve damage and pressure sores. "Patients can't protect themselves," says Michael Archdeacon, MD, chairman of the department of orthopedic surgery at the University of Cincinnati (Ohio) College of Medicine. "That's your job."

Positioning pointers
Proper patient positioning is critical during every procedure, from routine knee scopes to complex joint replacements, says Dr. Tucker. "During a 30-minute surgery, patients are lying motionless during prepping and draping, the pre-op time out and during anesthesia induction and emergence," he points out. "They're really positioned for longer than you think."

Here are a few positioning pointers for common orthopedic cases.

Knees. With the patient in the supine position, use a gel donut pad to make sure the head and neck are neutral. "I've had patients wake up after a lengthy surgery complaining of pain on the back of their head, where a pressure sore has started to form," says Dr. Tucker.

OFFERING ASSISTANCE The latest table attachments and positioning aids are designed for budget-conscious facilities and can eliminate the need for an assistant to hold extremities in place.

Place the patient's arms at his side at less than 90 degrees of abduction to limit tension on the rotator cuff. The palms and elbows should be facing up toward the ceiling to take pressure off the ulnar nerve. "You know that tingling sensation in your hand when you get hit square on the funny bone?" asks Dr. Tucker. "That's your ulnar nerve. Even if it's sitting on a soft cushion for extended periods, patients can wake up with a numb hand."

The pressure on the peroneal nerve is minimal when the patient is in the supine position. Sequential compression sleeves placed on the lower legs to prevent DVT also help relieve pressure in this area. As sleeves fill with air and constrict around the calves to help keep blood flowing, they lift the legs slightly off the surgical table. Make sure the sleeves are placed equidistant from the ankle and knee, so they're not pressing on any bony prominences. If a sleeve is placed too high on the leg, for example, it could put pressure on the popliteal space. Also, place the foot in a candy cane leg holder to allow access for prepping and draping the entire leg.

Shoulders. Dr. Tucker uses a beanbag positioner to place patients in a slightly lateral position and ensures the beanbag doesn't press on the patient's axilla. If patients are placed far lateral, says Dr. Tucker, make sure to position an axillary positioning roll in a way that keeps pressure off the brachial plexus. Also use a donut gel pad to make sure the head and neck are neutral. Confirm that the ear is in the center of the donut, so it's not being crushed, and that the pad is not pressing on the eye.

The patient's bottom arm should be placed out to the side. Position the elbow slightly off the table's surface to keep weight off the axillary nerve. The peroneal nerve in the lower leg is also vulnerable with the patient is the lateral position. Place a pad between the patient's thigh to ensure the fibular head is free; you should be able to slide your hand between the fibular head and the table to ensure the peroneal nerve is free and clear.

Use a soft pad at the lateral anklebone to ensure bony prominences are well padded. Place soft pillows between the patient's knees to keep them separated and also use a pillow to keep the knees slightly bent, because pressure is placed on the sciatic nerve or the hamstring if the knees straighten during the procedure.

Hips. Dr. Tucker approaches the hip joint laterally, so the positioning techniques he uses are much the same as those for shoulder procedures. One major difference: He uses a hip positioner to improve access to the joint and makes sure the positioner's pads are positioned to support the anterior iliac spine, and not pressing on the abdomen. When operating on heavier patients, he makes sure the abdomen is well padded. Adipose tissue that's not ideally positioned can compromise the surgeon's ability to approach the joint for maximum access. When patients are placed in the lateral position, make sure men's scrotums aren't stuck between their legs and women's breasts are hanging free.

Plenty of help available
Positioning patients for extremity procedures is more difficult than it is for central core surgery, says Dr. Archdeacon. The level of difficulty ramps up if, for example, he's operating on the left shoulder, but needs to stand on the right side of the patient to access the correct spot in the joint.

"Access to the shoulder is particularly critical and often challenging," says Dr. Archdeacon. "Patients must be positioned to provide three-quarter access to all areas of the joint."

He touts the use of foam, radiolucent positioning aids that increase patient comfort and are designed to position extremities for specific procedures. For example, he uses one pad specifically designed to protect and place patients in the lateral position for improved access to the shoulder and hip.

Dr. Archdeacon says adjunct positioning aids have evolved significantly in recent years — they nearly match the performance of custom positioners. The latest arm boards, leg holders, shoulder positioners and "beach chair" attachments feature low profiles and can be flipped between left and right configurations to turn conventional tables into surfaces suitable for complex joint procedures. Some newer traction devices attach to surgical tables and let surgeons position arms or legs without help from an assistant. Budget-conscious surgery centers interested in adding same-day joints can invest in specially designed table attachments that let surgeons perform the muscle-sparing anterior approach to the hip.

DIRECT ROUTE Proper patient positioning helps surgeons gain access to joints using their preferred surgical approach.

Clear expectations
Dr. Tucker has been called "meticulous" about the way he positions patients for surgery and wears the label with pride. "I'm the captain of the ship, so I'm responsible for making sure my patients are properly positioned," he says in a matter-of-fact sort of way, without a trace of chest-pounding bravado.

Dr. Archdeacon agrees that the responsibility falls on surgeons to clearly communicate with the surgical team precisely how patients need to be positioned and why that exact positioning is important for meeting the goals of surgery. He hits on patient positioning during pre-op huddles, which take place before the safety time out. During the quick gatherings, which often last less than 2 minutes, Dr. Archdeacon gets the surgical team on the same page with respect to how he wants the next patient positioned. Is a pressure ulcer forming? Do vulnerable areas on the skin need particular attention and padding?

"That communication is the critical element of proper positioning," he says. "If the surgical team members know and understand my concerns, they're better prepared to position the patient as needed for that particular procedure."

Surgeon preference cards note general positioning tips for the scheduled procedure, but discussions during pre-op huddles address issues or concerns specific to the patient on the table, says Dr. Archdeacon. He says the huddles improve the efficiency of the case preparation process and staff members have more buy-in with respect to how patients are placed and padded on the surgical table if they discuss the process with the surgeon minutes before a case begins.

Don't forget to consider intraoperative imaging when positioning patients. "For cases involving fluoroscopy, confirm that the patient is positioned in a way that will let you obtain the needed images," says Dr. Archdeacon. "There's nothing worse than positioning, prepping and draping the patient, bringing in the C-arm, and then realizing you can't capture what you need and having to remove the drapes and start the positioning process all over again."

Proper patient positioning is extremely important during trauma cases, so surgeons have the access they need to repair the broken bone. "If the patient is improperly placed on the fracture table, you might struggle to fix the bone properly," says Dr. Archdeacon.

Does Dr. Archdeacon remember a time when proper patient positioning let him operate on anatomy he would have otherwise had no shot in reaching? "No, I always remember when I didn't do a good job positioning patients, when I didn't get it right," he says. "That always made the surgery harder than it had to be." OSM