INTRAOPERATIVE PATIENT POSITIONING AND FLUOROSCOPY FOR FRACTURE SURGERY: A SUGGESTED GUIDE TO OBTAINING THE QUALITY IMAGES

Optimal patient position and placement of the image intensifier aids the surgeon in obtaining accurate, real-time radiographs during surgery. When radiographic images are easily accessible, total operating room (OR) time is decreased and more accurate assessment of reduction and implant placement can be achieved. Regardless of operative site, the position of the patient and image intensifier should allow maximum access to the operative field, minimize surgical site obstruction, and allow for easy duplication of necessary intraoperative biplanar imaging.

UPPER EXTREMITY

Fractures about the Shoulder (Proximal Humerus/Clavicle)

Proximal Humerus

• Patient placed in modified beach chair position

• A bump can be placed underneath the medial border of the scapula to turn the patient slightly to the contralateral side.

• The head is secured in a position in neutral rotation and flexion and the patient’s airway tube is secured, facing the noninjured side.

• Image intensifier is most easily brought into field from above the patient in order to obtain necessary anteroposterior (AP) and axillary views of surgical site (Fig. 53.1).

   

   

   

  Clavicle

• Patient placed in modified beach chair position

• Head secured in position with airway tube facing noninjured side

• The image intensifier is brought from the contralateral side of patient to allow optimal visualization of the medial aspect of the clavicle and sternoclavicular joint (Fig. 53.2).

   

   

   

  Fractures of the Humeral Shaft and Fractures about the Elbow

  Fixation of humeral shaft fractures and fractures about the elbow can both be accomplished with the patient either supine or lateral. The specific position utilized is based partly on surgeon preference and partly on fracture pattern, as fracture pattern may make one surgical approach preferable over another.

  Posterior Approach (Humeral Shaft, Distal Humerus, Olecranon)

• Patient positioned in lateral decubitus position stabilized with a beanbag. The affected extremity can be hung over an armrest for added support and to facilitate reduction.

• Axillary roll should be placed beneath the contralateral arm to minimize brachial plexus traction injury.

• Image intensifier is again brought in from the ipsilateral side and can easily obtain desired AP and lateral views.

• Can be reliably used for humeral shaft fractures or fractures about the elbow (Fig. 53.3)

   

   

   

  Direct Lateral and Anterolateral Approaches (Humeral Shaft, Distal Humerus, Radial Head, Proximal Radius, Proximal Ulna)

• Patient is positioned supine on radiolucent table. If desired, a hand table can be used.

• Patient translated to edge of bed so affected extremity can be freely manipulated to obtain necessary views of humeral shaft, distal humerus, or elbow.

• Image intensifier is brought in from ipsilateral side of patient to allow machine to be brought in or taken away as necessary (Fig. 53.4).

   

   

   

  Fractures about the Wrist/Hand

• Patient positioned supine with affected extremity centered on a hand table.

• The image intensifier is brought in from the ipsilateral side of the injured extremity. Images can be obtained by translating the injured wrist/hand onto the sterile image intensifier.

• Machine is brought in as necessary to obtain needed AP and lateral views without hindering access to the surgical field (Fig. 53.5).

   

   

   

  LOWER EXTREMITY

  Pelvis/Acetabulum

  Pelvis (Anterior Approaches and Percutaneous Iliosacral Fixation)

• Patient positioned supine on radiolucent table

• Bump is placed under the small of the patient’s back to increase lumbar lordosis and facilitate sacral imaging.

• Wide preparation of posterolateral buttock is crucial if iliosacral screws are being placed.

• Image intensifier is brought in from contralateral side of injured hemipelvis and tilted caudal and cephalad in order to obtain desired inlet/outlet views.

  • To verify proper inlet view, the upper sacral vertebral bodies are noted to be concentric circles.

  • To verify an ideal outlet view, the superior aspect of symphysis pubis should be superimposed on the S2 vertebral body.

• This setup is the same regardless of whether anterior or posterior fixation is needed.

• Lateral sacral view can easily be achieved from this position by swinging the image intensifier underneath the radiolucent table until the desired radiographic landmarks (i.e., iliocortical density) are identified.

  Acetabulum

  Posterior (Kocher-Langenbeck Approach)

• Patient positioned prone on a fracture table

• Hip is extended and the knee is flexed to approximately 80 to 90 degrees.

• Foot and peroneal post are well padded to minimize risk of skin or nerve injuries.

• The image intensifier is brought in from contralateral side of the patient to obtain desired AP and Judet views.

  Anterior (Ilioinguinal or Stoppa Approach)

• Patient is positioned supine on a radiolucent table

• The hip should be slightly flexed to relax the iliopsoas muscles and femoral nerve.

• Entire extremity is draped into surgical field, allowing manual traction to be applied, as well as leaving the option for lateral traction if deemed necessary intraoperatively.

• The image intensifier is brought into surgical field from the contralateral side to obtain necessary radiographic views while minimizing hindrance of surgical field.

  Percutaneous

• Patient is positioned supine on radiolucent table.

• Image intensifier brought in from the contralateral side and manipulated as needed to obtain necessary imaging.

• Required views (i.e., obturator oblique, inlet iliac oblique, inlet obturator oblique) are easily obtained through minor adjustments of x-ray beam to confirm fracture reduction and proper hardware position (Fig. 53.6).

   

   

   

  Hip Fractures

• Patient is placed supine on a standard fracture table with the affected limb secured in a boot after being well padded and firmly secured. A well-padded perineal post is used to further secure the patient on the table.

• The contralateral leg can then be scissored and secured to the metal post of the fracture table. Another technique is to place the unaffected leg on a well-padded leg positioner.

• Rotate patient’s torso to contralateral side of bed to optimize surgical access.

• Place ipsilateral arm across patient’s chest and secure it to contralateral side of table.

• Image intensifier is brought from contralateral side to obtain necessary imaging and avoid obstructing surgical field.

• Imaging beam can be angled obliquely in order to optimize x-rays. Image intensifier can be slid under table to obtain required cross table lateral radiographs (Fig. 53.7).

   

   

   

  Femoral Shaft Fractures

• Patient positioned supine on radiolucent table. A fracture table may also be used.

• If fracture table used, contralateral leg should be securely fastened to metal post of table or positioned in a well-padded leg holder to allow unhindered imaging of affected extremity (Figs. 53.7A,C).

• If positioned supine, the entire extremity is draped into the surgical field so assistant can easily apply manual traction.

• Image intensifier is brought in from contralateral side, allowing easily reproducible AP and lateral views of the affected femur (Fig. 53.8).

   

   

   

  Fractures about the Knee (Distal Femur Fracture, Tibia Plateau Fracture, Pate la Fracture)

• Patient is placed in supine position on radiolucent table.

• A bump is placed under ipsilateral hip if internal rotation of affected extremity is desired.

• Image intensifier is brought in from the contralateral side and AP and lateral views are easily obtained.

• A sterile bump can be used to elevate the operative extremity out of the plane of the uninjured extremity when obtaining the lateral view (Fig. 53.9).

   

   

   

  Tibial Shaft Fracture

• Patient is placed in supine position on radiolucent table.

• The image intensifier can be shifted more distally than when addressing fractures about the knee, leaving room for the knee to be hyperflexed.

• A radiolucent triangle can be used to hyperflex knee.

• Image intensifier is brought underneath the table to obtain lateral view to confirm safe passage of reamer and nail.

• If blocking screws are needed to obtain optimal nail position, their position can be easily confirmed with this setup (Fig. 53.10).

   

   

   

  Fractures about the Ankle (Ankle, Pilon, Calcaneus)

  Fractures about the ankle can be fixed with the patient either supine or prone. The position of the patient is dependent on the fracture pattern present as well as the surgical approach being utilized. Supine:

• Patient is positioned with bump under the ipsilateral hip if internal rotation of affected foot/ankle is desired.

• Image intensifier is brought in from contralateral side to obtain necessary AP, lateral, and oblique views of the ankle as well as any needed views of the foot.

  Prone:

• Patient is again positioned with ipsilateral bump to extend hip, allowing effected extremity to remain in different plane than uninjured extremity.

• Image intensifier is brought in from the contralateral side to allow easy, unobstructed imaging of the injured foot or ankle (Fig. 53.11).