Lateral decubitus position

The lateral decubitus position is used for the surgical exposure of periprosthetic fractures of:

The body of the scapula
The lateral column of the scapula
Acromiospinal fractures
Glenoid fractures

In addition, this position is used for:

The posterior approach to the humerus
Fractures in which the radial nerve needs to be exposed

Positioning the arm

The arm is draped free and supported on a well-padded bolster or frame.

This allows the surgeon to move the arm freely.

Reduction of periprosthetic scapula fractures may be facilitated by movement of the arm.

A rolled towel or soft support is used in the contralateral axilla to reduce the risk of injury to the brachial plexus and perfusion of the contralateral limb.

It is strongly advised to follow the steps of the WHO surgical safety checklist. This should be completed before:

Induction of anesthesia
Surgical incision

The options for anesthesia depend on:

The physiological condition of the patient
The shoulder condition being treated
Patient preference
Experience of the anesthetic physician

The options for anesthesia include:

General anesthesia
Regional nerve block
Combination of nerve block and light general anesthesia

Secure the patient’s body with padded side supports. Add a pad under the thorax to avoid axillary nerve compression injury in the contralateral shoulder. Confirm that there is no pressure on this shoulder.

Keep both legs flexed for a more stable position. Place a soft cushion under the lateral aspect of the knee to prevent excessive pressure on the peroneal nerve. Place a pillow or soft support between the legs.

To allow adequate access for imaging, position the patient as close as possible to the side of the table from which the arm will be accessed.

The contralateral arm should not interfere with intraoperative fluoroscopic imaging. It may be placed in 90° anteflexion of the shoulder and 90° elbow flexion.

Always ensure the anesthetist is satisfied with the position and support of the patient’s face and has adequate access to the airway at all times.

Take great care with the soft-tissue and skin pressure points, particularly in the elderly.

Pearl: Positioning the patient on a vacuum mattress helps to keep the body steady.

Lateral decubitus position – patient’s body is secured with padded side supports

For the posterior humeral approach

Position the operated arm with the shoulder with 90° flexion over a support or bolster with appropriate padding.

It should be possible to extend and flex the elbow beyond 90° to facilitate operative exposure.

A small, padded table can be placed under the forearm to support the elbow in extension if necessary.

If a tourniquet (sterile or nonsterile) is to be used, make sure the cuff is narrow so that it does not encroach on the area that requires exposure.

Position the operated arm with the shoulder with 90° flexion over a support or bolster with appropriate padding.

For the posterior humeral approach

Imaging can be performed with plain films or with the use of an image intensifier. Plain films are more appropriate if it is difficult to obtain adequate access with an image intensifier.

The C-arm can be brought in from the opposite side of the table in a horizontal orientation parallel to the floor. This allows for lateral images to be taken by raising the elbow.

C-arm positioning for lateral images with the patient in lateral decubitus position

AP images can be taken with the C-arm in the same position by rotating the shoulder. This technique keeps the C-arm away from the surgeons and in a fixed position throughout the operation.

The C-arm may also be introduced from the top of the table.

C-arm positioning for AP images with the patient in lateral decubitus position

For the posterior approach to the scapular body

A modified lateral decubitus position is used, with the patient in a more oblique position. This allows for better exposure of the scapular body.

A modified lateral decubitus position, with the patient in a more oblique position

The C-arm must be positioned from anterior to posterior. The orthogonal view is achieved by moving the C-arm in the horizontal plane.

The C-arm is positioned from anterior to posterior

Ensure there is adequate access for imaging before disinfecting and draping.

Disinfect the exposed area from the shoulder to the hand, including the axilla, with an antiseptic.

Apply an extremity drape to the affected arm, ensuring that sufficient coverage is achieved to access the surgical field. The hand is excluded by appropriate draping. The image intensifier is draped.