Authors of section


Peter V Giannoudis, Hans Christoph Pape, Michael Schütz

Executive Editors

Chris Colton, Rick Buckley

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Supine knee flexed 30°

1. Introduction

This position is useful for antegrade nailing or retrograde nailing as the ability to obtain AP and latera X-rays is exceptional.

Careful pre-cleaning of the soft tissues should be performed especially if gross contamination occurs.

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2. Preoperative preparation

  • Site and side of fracture
  • Type of operation planned
  • Ensure that operative site has been marked by the surgeon
  • Condition of the soft tissues (fracture open or closed)
  • Implant to be used
  • Patient positioning
  • Details of the patient (including a signed consent form and appropriate antibiotic and thromboprophylaxis)
  • Comorbidities, including allergies

3. Anesthesia

This procedure is performed with the patient under general or regional anesthesia.

If a spinal anesthetic is used, the surgeon and anesthetist need to be confident that the procedure will not last more than 1.5 hours.

Long-lasting postoperative complete pain blocks for the injured leg should be avoided as this could hide symptoms of a subsequent compartment syndrome.

4. Patient and x-ray positioning

  • Position the patient supine with roll or well-padded sandbag under the thigh to keep the knee in a 30° flexed position. Alternatively, a carbon triangle may be used.
  • Carefully pad all pressure points, especially in the elderly.
  • Position the image intensifier on the opposite side of the injury and the surgeon.
  • Before preparing and draping, ensure good AP and lateral image intensifier views can be obtained.
  • If manual traction is required to reduce the fracture, try to achieve this before preparing and draping the patient.
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5. Skin disinfecting and draping

  • Maintain light manual traction (the assistant may need to stand on a stool) on the limb during preparation to avoid excessive deformity at the fracture site.
  • Disinfect the exposed area from above the iliac crest to the foot with the appropriate antiseptic.

supine knee flexed 30
  • Drape the limb with a single-use U-drape. A stockinette covers the lower leg and is fixed with a tape. The leg is draped so as to be freely moved.
  • Drape the image intensifier.
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6. Operating room set-up

  • the surgeon and ORP stand on the side of the affected limb.
  • The assistant stands next to the surgeon.
  • Place the image intensifier on the opposite side of the injury and the display screen in full view of the surgical team and the radiographer.

supine knee flexed 30