For prone positioning, a spine table (A, B) versus a flat top (C, D) can be utilized based on patient size and procedure. A spine table with adequate padding to minimize pressure points is key.
Courtesy of Julie Balch Samora, MD, FAAOS

AAOS Now

Published 2/1/2020
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Austin A. Cole, MD

Avoid Patient Harm by Improving Patient Positioning for Surgery

Perioperative positioning may not always get the attention it deserves. Surgeons and operating room (OR) staff are often preoccupied with other tasks and thoughts, and they may consider positioning routine and safe. Surgeons often delegate positioning responsibility to circulating nurses, scrub technicians, and physician assistants (and in teaching hospitals, residents).

In many institutions, the status quo includes complacency regarding patient positioning. Given the preventable risk of patient harm due to poor positioning, intentional individual and hospital strategies about positioning can reduce that risk of harm. For such changes to take place, it is critical that the orthopaedic surgeon, as captain of the ship, set an example by being a champion of safety culture, including participating in timeouts and prioritizing proper patient positioning.

Positioning and potential risks can be part of the preoperative huddle. It is helpful to verify the condition of positioning devices and to check the function and position of padding and devices each time a patient is repositioned. Moving an unconscious patient is safer with adequate personnel and upon permission from the anesthesia team. In addition, anesthetists may be more familiar with the various physiologic changes associated with positioning.

Peripheral nerve injury is the most frequently discussed positioning-related harm and the third most common cause of anesthesia litigation. Nerve injuries can result from ischemia, compression, or stretch. Injury can occur after three hours of compression or ischemia. Peripheral nerves can be injured if they are stretched to more than 5 percent to 15 percent of their resting length.

Pressure injuries are certainly preventable but remain a prevalent harm. Most (95 percent) pressure ulcers occur over inadequately padded bony prominences.

Ocular injuries include corneal abrasion, retinal artery occlusion, and ischemic optic neuropathy. Surgeons must be cognizant that almost anything can cause corneal abrasions—from anesthesia tape to a physician’s elbow. Ocular ischemia may result from external pressure on the globe or inadequate intraoperative perfusion. If severe, postoperative vision loss could follow.

Five common orthopaedic positions and their related risks

Supine
Arms should be placed on arm boards or at the patient’s sides at the same height as the table and parallel to the floor. Placement of arm boards at greater than 90 degrees abduction, or a difference between the height of the arm boards and the bed, may contribute to stretch injury to the brachial plexus. Elbow padding limits compression on the ulnar nerve. Positioning the hand into neutral will help rotate the ulnar nerve into a safe position. Slight flexion at the elbow will decrease risk of stretching peripheral nerves. Padding should be placed under the heels to avoid pressure problems. Finally, pressure on concealed limbs from equipment or surgeons may contribute to compression injuries to nerves or muscles, including compartment syndrome.

Traction table
When a traction table is used with a patient supine, traction on the operative leg is applied with a padded foot piece. The nonoperative leg is frequently dropped below the operative side to provide sufficient lateral imaging. Extension of the hip may result in stretching of the femoral nerve. In addition, severe osteoarthritis or conditions limiting range of motion may lead to minimal extension. If a well leg holder is used, adequate padding around the fibular head is crucial to protect the peroneal nerve.

The incidence of pudendal nerve palsy ranges from 1.9 percent to 28.0 percent. Insufficient padding of the post or excessive traction against the post may lead to nerve palsy, with sequelae ranging from transient sexual dysfunction to genitoperineal skin necrosis. To avoid those risks, some surgeons have adopted new commercially available friction pads that allow for successful distraction without the use of a perineal post. Excessive traction of the operative extremity is also a common cause of injury, as it may stretch peripheral nerves. As such, it is critical to balance the desire to use more traction to facilitate visualization with awareness of the potential risk of traction nerve injuries, which are dependent on degree of traction and time. The most commonly injured nerves are the common peroneal and sciatic.

For prone positioning, a spine table (A, B) versus a flat top (C, D) can be utilized based on patient size and procedure. A spine table with adequate padding to minimize pressure points is key.
Courtesy of Julie Balch Samora, MD, FAAOS
Arm is placed at 45 degrees, which is the safest position for the shoulder and brachial plexus. Also note slight external rotation of the hand to protect the ulna.
Courtesy of Alan M. Reznik, MD, MBA, FAAOS
Well leg pillow to protect nonoperative side.
Courtesy of Alan M. Reznik, MD, MBA, FAAOS

Lateral decubitus
Brachial plexus palsy is the most common peripheral nerve injury in the lateral decubitus position. The brachial plexus may be compressed between the thorax and the humeral head on the patient’s downside. Space between the trunk and the table, such as a soft axillary roll, helps limit this problem. A roll should be applied under the chest and not in the axilla itself, approximately two to three finger breadths caudal to the axilla. Average pressure under the shoulder has been shown to decrease from an average of 66 mmHg to 20 mmHg with adequate positioning of an axillary roll. Lateral angulation of the neck may also stretch the contralateral brachial plexus and can be limited with inflatable pillows or elevated gel pads.

Prone
In the prone position, excessive padding under the abdomen may result in elevated intra-abdominal pressure. This may lead to compression of the inferior vena cava, reduced venous return to the heart, and consequent low cardiac output. The chest support can be excluded from the axilla to protect the brachial plexus.

With the head positioned face down, various facial pressure injuries may result. Some contributing factors include selection of padding material, angle of neck position, shear and friction forces, and moisture.

Postoperative vision loss is one of the more serious positioning-related complications. Prone positioning and anesthesia have been shown to decrease intraocular perfusion through a variety of physiologic mechanisms. Modifiable risk factors include external pressure on the globe, neck flexion greater than 15 degrees, mean arterial pressure, case duration, and blood loss. The American Society of Anesthesiologists Task Force on Perioperative Visual Loss considers case length of more than 6.5 hours and blood loss exceeding 44.7 percent of volume risk factors for impairment.

Beach chair
In this position, the hips and knees are both flexed. Raise the front and back of the bed stepwise to reduce shear and friction forces and thus decrease the risk of pressure injuries and nerve stretch. Once a patient has been placed into the sitting position, assess the patient again to eliminate any compressive forces that may have risen during the process. Ensure adequate padding of the heels. The elbow should receive special attention, as ulnar nerve neuropraxia may occur in this position. Inadequate padding under the safety belt may lead to compression of the lateral femoral cutaneous nerve and subsequent numbness or paresthesia. In this upright position, cervical neuropraxia may ensue if the head is allowed to slump to one side. Cerebral hypoperfusion is a potential catastrophic danger; thus, frequent communication between the surgeon and anesthetist is critical.

Conclusion

Many surgeons and OR staff pay inadequate attention to intraoperative positioning. However, serious complications are related to the specific position in each surgery, and adequate knowledge of the potential harms is imperative for planning and prevention. Orthopaedic surgeons should lead the process and clearly communicate their preferences and the risks associated with poor positioning. Hospitals should assist with education, implement quality-improvement strategies, and provide the necessary equipment to ensure safe patient positioning. Adequate surgical exposure should be a priority, but patient safety should never be sacrificed. In addition, length of surgery and duration of anesthesia greatly increase the risk of nerve injury and pressure ulcers; as such, extra caution is warranted for longer cases. We should consider Hippocrates, who advised primum non nocere.

Austin A. Cole, MD, is a post-graduate year-2 orthopaedic surgery resident at Prisma Health System in Greenville, S.C. He is an active resident representative on the AAOS Patient Safety Committee. He can be reached at austin.cole@prismahealth.org.

Michael T. Archdeacon, MD; David C. Ring, MD, PhD; and Julie Balch Samora, MD, PhD, FAAOS, contributed to this article.

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