Patient Positioning in

Orthopaedic Surgery
R2, September 2020
Sub Topics
• Supine
• Lateral Decubitus
• Prone
Supine
Supine
• The most common position
• one or both of the patient’s arms  abducted out or adducted (tucked)
• Upper extremity abduction less than 90 degrees to minimize brachial plexus injury.
• The hand and forearm  supinated or in a neutral position (palm toward the
body) to reduce external pressure on the spiral groove of the humerus and the ulnar
nerve
• The arms adducted  use “draw sheet” that passes under the body, over the arm, and is
then tucked directly under the torso (not the mattress) to ensure that the arm remains
properly placed next to the body.
Supine
Variance of Supine
• lawn chair position
• frog-leg position
• Trendelenburg position
• reverse Trendelenburg position (head-up tilt)
lawn chair position
• the hips and knees are slightly flexed  reduces stress on the back, hips, and knees
• Venous drainage from the lower extremity
is facilitated.
• The xiphoid-to-pubic distance is decreased  reducing the tension on the ventral
abdominal musculature  easing the closure of laparotomy incisions.
lawn chair position
frog-leg position
• The hips and knees are flexed and the hips are externally rotated with the soles of the
feet facing each other  allows access to the perineum, medial thighs, genitalia, and
rectum.
• Care must be taken to minimize stress and postoperative pain in the hips and to prevent
dislocation by appropriately supporting
the knees.
frog-leg position
Trendelenburg position
• Used to increase venous return during hypotension, to improve exposure during
abdominal and laparoscopic surgery, and during central line placement to prevent air
embolism and distention of the central vein.
• Increases central venous, ICP, and intraocular pressures.
• Prolonged head-down positioning  swelling of the face, conjunctiva, larynx, and tongue
 increased potential for postoperative upper airway obstruction.
• The cephalad movement of abdominal viscera  decreases FRC and pulmonary
compliance.
• Spontaneously ventilated patient  WOB increases.
• Mechanically ventilated Patient  airway pressures must be higher
• The stomach also lies above the glottis  ET use to protect the airway from aspiration of
gastric contents related to reflux and to reduce atelectasis.
reverse Trendelenburg position (head-up
tilt)
• Used to facilitate upper abdominal surgery by shifting the abdominal contents caudad.
• Caution is advised to prevent patients from slipping on the table, and more frequent
monitoring of arterial blood pressure may be prudent because hypotension may result
from decreased venous return.
• In addition, the position of the head above the heart reduces perfusion pressure to the
brain and should be taken into consideration when determining optimal blood pressure
and the zero position of an arterial pressure transducer, when present.
Complications
• Pressure alopecia, caused by ischemic hair follicles, is related to prolonged
immobilization of the head with its full weight falling on a limited area, usually the
occiput.
• Backache may occur in the supine position because the normal lumbar lordotic
curvature is often lost during general anesthesia with muscle relaxation or a neuraxial
block due to their effects on the tone of the paraspinous muscles.
• Peripheral nerve injury is a complex phenomenon with multifactorial causes. Ulnar
neuropathy has historically been the most common lesion, although brachial plexus
injuries have superseded ulnar neuropathies in more recent closed claims data
associated with general anesthesia.
• ASA Practice Advisory recommends limiting arm abduction in the supine patient to less
than 90 degrees at the shoulder with the hand and forearm either supinated or kept in a
neutral position.
Lateral Decubitus
Lateral Decubitus
• The lateral decubitus position  thorax surgery, retroperitoneal structures, or hip.
• The patient rests on the non operative side and is balanced with anterior and posterior support
• The arms are usually positioned in front of the patient
• The dependent arm rests on a padded arm board perpendicular to the torso. The nondependent
arm is often supported over folded bedding or suspended with an armrest or foam cradle
• The patient’s head must be kept in a neutral position to prevent excessive lateral rotation of the
neck and stretch injuries to the brachial plexus.
• The dependent ear should be checked to avoid folding and undue pressure. The eyes should be
securely taped closed before repositioning if the patient is asleep. The dependent eye 
frequently checked
• To avoid compression to the dependent brachial plexus or blood vessels, an axillary roll,
which is generally a bag of intravenous fluid, is frequently placed between the chest wall and
the bed just caudal to the dependent axilla
• Lastly, a pillow or other padding is generally placed between the knees with the
dependent leg flexed to minimize excessive pressure on bony prominences and stretch
of lower extremity nerves.
Prone
• Ventral decubitus position  surgical access to the posterior fossa of the skull, the posterior
spine, the buttocks and perirectal area, and the lower extremities.
• the patient’s legs should be padded and flexed slightly at the knees and hips.
• The head may be supported facedown with its weight borne by the bony structures or turned to
the side.
• Both arms may be positioned to the patient’s sides or placed next to the patient’s head on arm
boards—sometimes called the prone superman position
• Extra padding under the elbow may be needed to prevent compression of the ulnar nerve.
• The arms should not be abducted > 90 degrees to prevent excessive stretching of the brachial
plexus
• GA  The trachea is first intubated on the stretcher, and all intravascular access is obtained as
needed. The endotracheal tube is well secured to prevent dislodgement and the loosening of
tape as a result of the drainage of saliva when prone.
• Head position is critical. The patient’s head may be turned to the side when prone if
neck mobility is adequate.
• In most cases, the head is kept in a neutral position using a surgical pillow, horseshoe
headrest,
or Mayfeld head pins.
• External pressure on the abdomen may elevate both intraabdominal and intrathoracic
pressures.
• Pulmonary function may be superior to the supine and lateral decubitus positions if no
signifcant abdominal pressure is present and if the patient is properly positioned.
• To promote low abdominal and thoracic pressures, firm rolls or bolsters placed along
each side from the clavicle to the iliac crest generally support the torso.
Terima Kasih