Authors of section

Authors

Theerachai Apivatthakakul, Jong-Keon Oh

Executive Editor

Michael Baumgaertner

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Supine patient position on a radiolucent table

1. Indications

Supine patient positioning is used for most of the surgical management of trochanteric and femoral neck fractures. The use of a radiolucent table allows for intraoperative manipulation of the leg. The contralateral thigh can interfere with lateral image intensifier views. A hemilithotomy or lifting the contralateral limb while taking the lateral view may be helpful.

Supine patient position on a radiolucent table for surgical treatment of proximal femoral fractures

2. Preoperative preparation

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

  • Site and side of the fracture
  • Type of operation planned
  • Ensure that the surgeon has marked the operative site
  • 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. Perioperative care for elderly hip-fracture patients

Routine perioperative care includes:

  • Brief intravenous antibiotics
  • VTE prophylaxis (before, during, and after surgery)
  • Nutritional supplementation
  • Pain management without oversedation
  • Prevention of pressure sores
  • Early mobilization
  • Early discharge planning
  • Osteoporosis evaluation and management

For more details, see the additional material on perioperative care for elderly hip fracture patients.

4. Anesthesia

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

5. Patient positioning

Place the patient supine and as close as possible to the edge of the table.

Lift the pelvis with a folded sheet under the ipsilateral buttock and tilt the table. A lateral support at the level of the contralateral iliac crest is required to prevent the pelvis from migrating to the contralateral side.

For optimal lateral and axial views, the patient may be positioned in a hemilithotomy (contralateral leg in a leg holder).

Supine patient position on a radiolucent table for surgical treatment of proximal femoral fractures

6. C-arm positioning

With the table tilted, the AP image can be obtained with a vertical beam.

For a lateral and axial view, roll the C-arm under the table. The beam track should avoid the contralateral hip.

Supine patient position on a radiolucent table with the C-arm positioned for a lateral view of the proximal femur

Position the patient in a hemilithotomy (contralateral leg in a leg holder) to obtain optimal lateral and axial views.

Supine patient position on a radiolucent table with the contralateral leg in a leg holder and the C-arm positioned for a lateral view of the proximal femur

7. Closed reduction

For undisplaced fractures, the surgeon can proceed with skin preparation and draping and then on to exposure for fixation. If the fracture is displaced, closed reduction should be carried out at this point. If it is unsuccessful, percutaneous manipulation or formal open reduction will be necessary, and the incision must be planned appropriately.

8. Intraoperative options for VTE prophylaxis

During the operation, some centers provide VTE prophylaxis with sequential mechanical compression on the contralateral leg.

Supine patient position on a radiolucent table with the contralateral leg in a leg holder and VTE pump for surgical treatment of proximal femoral fractures

9. Skin disinfection and draping

Before draping, make sure proper image intensifier view in AP, lateral, and directions can be obtained.

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 solution.

Free drape the affected limb(s) with a single-use U-drape. A stockinette covers the lower leg and is fixed with tape. The leg is draped to be freely moved.

Drape the image intensifier.

Skin disinfection and free draping of a patient position on a radiolucent table for surgical treatment of proximal femoral fractures

10. Operating room set-up

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.

Operating room set-up with the patient supine on a radiolucent table for surgical treatment of proximal femoral fractures
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