Positioning Is Paramount in Orthopedics

Orthopedics

By: Kendal Gapinski

Published: 7/14/2020

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Protect patients and ensure surgical access during hip, knee and shoulder procedures.


The proper positioning of patients undergoing orthopedic procedures prevents nerve and skin injuries and gives surgeons better access to the joints they're repairing or replacing. Spending a few extra minutes before cases begin to make sure knees are flexed, hips are hyperextended and shoulders are secured pays off in successful outcomes and safer patient care. Charlene DiNobile, RN, M.Ed, CNOR, CST, NEA-BC, CSPDT, CFER, a professor at the New England Institute of Technology, says you should focus on these pillars of proper positioning:

  • Primary goals. Focus on protecting muscles, nerves and bony prominences, ensure adequate exposure of the operative site and maintain a functional airway. Take extra care of high-risk patients such as the elderly and those with comorbidities, especially diabetes or vascular disease. Consider the patient's overall skin condition, friction and shearing risks during surgery and expected length of the case when determining pressure injury risk reduction strategies.
  • Positioning aids. Utilize effective positional aids by basing your choices on evidence-based practice. Take the time to review manufacturers' details on cleaning, usage and safety. Make sure you have access to the latest instructions for use and staff and physician competency information.

Don't rely on egg crate foam surfaces and traditional pillows, as they do not distribute pressure effectively and tend to compress quickly under the weight of the patient's body. If you are using these types of materials, however, it's best to support low weight-bearing areas, such as under the knees.

Finally, confirm that needed positioning aids are on hand and ensure staff have the working knowledge, through in-servicing, of how to use each device safely and effectively.

  • Skin checks. Assess and document the patient's skin condition before surgery. Reassess skin integrity during cases involving patients who are in the supine or prone position for more than six hours and the lithotomy or lateral decubitus position for more than three hours. Agree upon times during lengthier cases when the surgical team will perform skin assessments at pressure points, conduct range of motion exercises and reposition the patient as needed.

It's also crucial to assess the patient's risk for a positioning complication. "Gain as much information as you can about their range of motion status in pre-op," says Jenni Prevatt, MS, RN, CNOR, quality improvement nurse analyst and surgical nurse reviewer at UC Davis Children's Hospital in Sacramento, Calif. "Explain to the patient how they will be positioned during surgery. That way, they'll be more likely to speak up if they foresee a positioning issue based on their known range of motion limitations."

Knees
HOLD STEADY Innovative positioning devices are designed for ease of use, increased stability and improved traction.

Knee replacement patients are typically placed in the supine position, with arms on armboards and the operative knee propped or flexed. Be sure these areas are padded and protected when patients are in supine position:

  • Occiput. Many anesthesia providers prefer to use a foam "donut" to stabilize the head. However, during prolonged procedures involving patients who have sustained low mean arterial pressures (MAPs), these devices have caused deep tissue injuries at the back of the head. It's better to use the foam donut during intubation before switching to an air-filled pressure redistributing pad or fluidized positioner pillow.
  • Sacrum. Sacral deep-tissue injuries occur often on patients in the supine position because it's difficult to reposition or offload pressure from the sacrum during surgery. To protect the sacral area, use an atraumatic foam silicone dressing that covers the entire bony prominence in conjunction with an air-filled pressure redistributing pad. The air-filled pad distributes pressure and the foam dressing protects the skin from shearing forces.
  • Arms. Place the arms on armboards with palms facing up. Make sure the arms are abducted at less than a 90-degree angle. Hyperextending the arm can cause brachial plexus nerve injuries. Secure arms to armboards and pad elbows with gel, foam or air-filled pressure redistributing pads.
  • Heel. Pad the non-operative heel with gel, foam or air-filled pressure redistributing pads.

For other procedures, such as arthroscopic anterior cruciate ligament reconstruction, the non-operative leg may be positioned in a stirrup in low lithotomy. This can prove risky.

"Carefully place the leg in the stirrup and make sure it's secured," says Ms. Prevatt. "In low lithotomy, the hips should be flexed no more than 60 degrees from the table's surface. Too much flexion or abduction can injure the sciatic nerve."

Hips
FROM ALL ANGLES Placing hip replacement patients on their side gives surgeons posterior or lateral access to the joint.

Hip arthroplasty is performed with a posterior approach, direct lateral approach or direct anterior approach. The anterior approach requires placing the patient in the supine position with the leg on the side of the operative hip hyperextended to just off the floor. Operating at the front of the hip is a muscle-sparing technique that results in shorter recoveries, but is technically demanding for surgeons to perform. The lateral approach can be performed with the patient in the lateral decubitus position or supine position. The posterior approach is performed with the patient in the lateral decubitus position. Ms. Prevatt suggests protecting the following areas when placing patients laterally:

  • Face, ear and head. Align the head with the spine. Ensure the ear is not folded over because this could cause tissue ischemia and lead to skin breakdown. Blankets and pillows can be used to build up a surface for alignment, however an air-filled pressure redistributing pad or fluidized positioner pillow on top of the pile will provide more pressure-relief than foam, traditional pillows or blankets.
  • Dependent shoulder. Support the shoulder with a soft axillary roll just distal to the axilla. This allows for better blood flow to the lower extremities and prevents nerve injuries to the arm and hand. The axillary roll should not be made by rolling up a blanket or towel because these surfaces have very little pressure redistributing qualities and would apply significant pressure to skin over the thoracic area.
  • Dependent arm. Secure the arm on an armboard and make sure it's abducted at no more than a 90-degree angle. Pad the elbow.
  • Dependent hip. Apply a silicone foam dressing to prevent skin tearing from shear forces. Also place an air-filled pressure redistributing pad under the trochanter to reduce pressure on the bony surface.
  • Dependent leg. An air-filled pressure redistributing pad can be used under the lateral knee and ankle. Pillows may be used under and between the knees, but keep in mind that pillows and foam compress quickly, which decreases their pressure-redistributing qualities.
Shoulders

Surgeon preference determines how patients are positioned for shoulder surgery; some prefer the lateral decubitus position and others utilize beach chair positioning. Each option has associated benefits and drawbacks. The lateral decubitus position improves visualization of and access to lateral pathology during stabilizing procedures. However, the position involves placing patients in a non-anatomic position and can increase the risk of thromboembolic complications. The beach chair is a more anatomic position that reportedly results in fewer neurovascular complications and provides increased visualization of the entire joint. It can lead to higher rate of hypotensive and bradycardic events, and limits access to the posterior areas of the joint. Ms. Prevatt says there are several high-risk areas to protect on patients placed in the beach chair position:

  • Non-operative arm. The arm is often supported on the patient's abdomen in a sling or holder, or on an armboard. When using an armboard, place the arm with the palm facing down. Pad the elbow and secure the arm to the armboard.
  • Sacrum. To protect the sacral area, use an atraumatic foam silicone dressing that covers the entire bony prominence in conjunction with an air-filled pressure redistributing pad under the sacrum. The air-filled pad distributes pressure and the foam dressing protects the skin against shear forces.
  • Knees and hips. Position the table so the hips are angled to 60 degrees and the knees are angled to 30 degrees. Use pillows to support under the knees.
  • Heels. Place gel, foam or air-filled or fluidized pressure redistributing pads under the feet to lift the heels off the table surface.

When positioning patients laterally with a bean bag positioner, make sure the device is clean, in good working order and free from leaks, suggests Ms. DiNobile. She recommends having a designated team member check for excessive pressure on male genitals and female breasts at regular intervals during surgery. Additionally, says Ms. DiNobile, make sure a staff member is assigned to hold the patient's head while securing the positioning aid.

Post-op precautions

Recheck patients' skin in recovery, looking for redness or signs of neurological injuries, and educate patients on how to self-assess for pressure-related complications when they return home, says Ms. Prevatt.

Improving your patient positioning protocols should start outside of the OR, with your facility developing and implementing guidelines with input from your surgical team and PACU nurses, says Ms. DiNobile. "Don't wait for a poor outcome," she adds. "For the continuing safety of your patients, all surgical team members must be instructed on patient positioning risks and follow best practice on every patient, every day." OSM

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