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.
Operating room personnel (ORP) need to know and confirm:
Routine perioperative care includes:
For more details, see the additional material on perioperative care for elderly hip fracture patients.
This procedure is performed with the patient under general or regional anesthesia.
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).
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.
Position the patient in a hemilithotomy (contralateral leg in a leg holder) to obtain optimal lateral and axial views.
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.
During the operation, some centers provide VTE prophylaxis with sequential mechanical compression on the contralateral leg.
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.
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.