Supine with manual traction

This positioning is recommended for antegrade nailing and bilateral fractures because it can allow for the reduction and fixation of both fractures without requiring re-draping. However, the axial view may be difficult to obtain because elevation of the contralateral leg is required.

Operating room personnel (ORP) need to know and confirm:

• Site and side of the fracture
• Type of operation planned
• Ensure that the 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

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

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

• Reconfigure the table or transfer the patient to a fracture table.
• Reduce the fracture with manual traction and manipulation to ensure reduction is possible before preparing and draping the patient.
• Pad all pressure points carefully (especially in the elderly).
• Position the image intensifier on the opposite side of the injury and the operating surgeon
• Ensure that you can get good-quality AP and lateral x-ray views of the entry point (piriform fossa), fracture site, and distal femur before draping.
• In obese patients it may be technically easier to perform antegrade femoral nailing in a lateral position without skeletal traction. Place the patient lateral (or supine with a large sandbag under the ipsilateral buttock) on a radiolucent table.
• Adduct and slightly flex the affected leg anteriorly in front of the unaffected one to ensure the position is reasonable for obtaining X-rays.
• A firm cushion placed in the midline beneath the pelvis may be used to elevate the pelvis from the table edge and facilitate the skin incision.
• The ipsilateral arm should not be positioned on an arm board or abducted, since it would interfere with nail insertion. An adducted (pictured) or elevated position is favored.
• The surgeon must be satisfied with the position before the patient is prepared for surgery.

• Maintain light manual traction on the limb during preparation to avoid excessive deformity at the fracture site.
• Disinfect the exposed area from above the iliac crest to the mid-tibia with the appropriate antiseptic.
• Free drape the affected limb(s) with a single-use U-drape. A stockinette covers the lower leg and is fixed with a tape. The leg is draped to be freely moved.
• Drape the image intensifier

• The surgeon, assistant, and ORP stand on the side of the injury.
• Place the image intensifier on the opposite side of the injury or surgeon.
• Place the image intensifier display screen in full view of the surgical team and the radiographer