Authors of section


Derek Donegan, Michael Huo, Michael Leslie

Executive editor

Michael Baumgaertner

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Supine position with manual traction

1. Introduction

The patient is positioned supine on a conventional table and moved as close as possible to the edge of the table. The pelvis is lifted up by a folded sheet under the ipsilateral buttock.

Note: for periprosthetic fractures, whether performing ORIF or revision arthroplasty, it is preferred to position the patient on a radiolucent table.
OR setup for supine patient positioning

2. Preoperative preparation

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

  • Site and side of fracture
  • Type of operation planned
  • Ensure that operative site has been marked by the surgeon
  • Condition of the soft tissues
  • 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.

4. Positioning

  • 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 fracture site, full prosthesis, and distal femur before draping.
  • In obese patients it may be technically easier to perform the surgery on a lateral position 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 could interfere with the surgical procedure. An adducted (pictured) or elevated position is favored.
  • The surgeon must be satisfied with the position before the patient is prepared for surgery.
Patient in supine position

5. Skin disinfecting and draping

  • 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.
Draping for a patient in supine position

6. 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 setup

7. Option: use of a radiolucent or fracture specific table

A radiolucent table or a fracture specific table, that can provide traction through the foot and ankle, may be used.

The choice depends on surgeon's experience and preference.

Supine positioning on a fracture specific table
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