17 Upper extremities
17.1 Shoulder – 218 17.1.1 Supine position – 218 17.1.2 Beach-chair position – 220 17.1.3 Prone position – 222
17.2 Upper arm – 224 17.2.1 Supine position – 224 17.2.2 Prone position – 226
17.3 Elbow – 228
17.3.1 Supine position – 228
17.3.2 Prone position – 230
17.4 Forearm and hand – 232
17.4.1 Supine position – 232
17
17.1 Shoulder
17.1.1 Supine position
. Figs. 17.1, 17.2.
Indications
Ventral, axillary, transdeltoid access to the shoulder joint, access to the clavicle and to the acromioclavicular joint for fractures, pseudarthrosis, posttraumatic misalignment, luxation, instability, tumours, inflammation and rupture of the biceps tendon.
Preparations
4
Arm positioning devices
4Remove Gilchrist bandage
4Gel ring
4
Shaving in the area of the incision and preoperative skin cleansing Positioning
4
Standard operating table position 1, position 2 or universal operating table with X-ray protection, clavicle remains available for scanning
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
Tilt the operating table in the Trendelenburg position, raise the back plate by 20–30°, lower the leg plates and the head section by hand
4
Position the head on a gel ring, possibly slightly turned to the other side and reclined
4
Position the infusion arm on an arm positioning device
4
Pad the shoulder with a positioning aid, thus raising the operating site or joint being operated
4
Cover the arm on the side being operated while leaving it free to move and position it at the body with arm protection or place it on the arm posi- tioning device
4
Apply the neutral electrode and connect to the HF surgery device
4Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system
. Fig. 17.1. Supine position with arms posi- tioned at the body (arm protection with padding)
. Fig. 17.2. Supine position on special shoul- der plate with the advantage of scanning and the head on a one-piece horseshoe-shaped headrest
17.1 · Shoulder
17
17.1.2 Beach-chair position
. Figs. 17.3–17.7.
Indications
Ventral, transdeltoid access to the shoulder joint, access to the clavicle and to the acromioclavicular joint for fractures, pseudarthrosis, posttraumatic mis- alignment, luxation, instability, tumours, inflammation, rupture of the biceps tendon, arthrosis, impingement syndrome and rotator cuff lesions.
Preparations
4
Arm positioning devices
4Remove Gilchrist bandage
4Gel ring
4
Shaving in the area of the incision and preoperative skin cleansing Positioning
4
Beach-chair (BC) operating table position 2 or universal operating table with special back plate
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
The patient’s shoulders end at the upper edge of the operating table
4Bring the operating table gradually to the half-sitting (beach-chair)
position
4
Raise the back plate and alternately lower the head of the complete opera- ting table until the final position is reached
4
Change the Bowden cable over and lower the legs to the horizontal po sition (system 1120)
4
Position the head on a gel ring and fix with transparent plaster right across the forehead or use a head support for shoulder operation (U-shaped helmet)
4
Position the infusion arm on an arm positioning device
4
Cover the arm on the side being operated while leaving it free to move and position it at the body with arm protection or place it on the arm positio- ning device
4
Apply the neutral electrode and connect to the HF surgery device
4Fit the thorax support to the side rail of the shoulder plate
4Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system Risks
4
Iatrogenic injuries to the eyes and soft tissues (head fixing) when fixed with plaster or foil
4
Secondary dislocation
. Fig. 17.7. Thorax support
. Fig. 17.6. A segment is removed to leave free access to the rear shoulder
. Fig. 17.5. The universal operating table with special shoulder plate is adapted to the body
. Fig. 17.3. Beach-chair positioning on special shoulder plate with helmet for safe positioning of the head
. Fig. 17.4. The thorax support offers additional safety 17.1 · Shoulder
17
17.1.3 Prone position
. Figs. 17.8, 17.9.
Indications
Dorsal and transacromial access to the shoulder joint and access to the scapu- la for luxation, fractures, posttraumatic misalignment, instability, tumours, rotator cuff lesions.
Preparations
4
Arm positioning devices
4
Special head positioning cushion for prone position
4Thorax, pelvic and wedge cushion, padded roll
4
Shaving in the area of the incision and preoperative skin cleansing Positioning
4
Standard operating table position 1, position 2 or universal operating table
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Transfer to the prepared operating table in the induction room
4Position both tables next to each other, with the prepared table lowered
4Place the patient in prone position on the padded cushion of the prepared
operating table and take him into the theatre
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
Position the head on the special head positioning cushion
4Position both arms on the arm positioning devices
4
Apply the neutral electrode and connect to the HF surgery device
4Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system
. Fig. 17.8. Prone position with small arm plate/upper arm plate
. Fig. 17.9. The distal joint is positioned lower than the proximal joint
17.1 · Shoulder
17
17.2 Upper arm
17.2.1 Supine position
. Figs. 17.10–17.13.
Indications
Extended ventral access to the shoulder joint and ventral, medial and lateral access to the humerus for fractures, pseudarthrosis, posttraumatic misalign- ment, tumours, inflammation, nerve lesions.
Preparations
4
Arm positioning devices
4Remove Gilchrist bandage
4
Shaving in the area of the incision and preoperative skin cleansing Positioning
4
Standard operating table position 1, position 2 or universal operating table with X-ray protection
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
Standard supine position, infusion arm is spread out
4
Remove the arm positioning device and fasten the large arm table to the side rail of the back plate
4
Position the patient near to the edge of the table
4
Apply the neutral electrode and connect to the HF surgery device
4Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system
. Fig. 17.10. Arm positioning on large arm table
. Fig. 17.11. 360° fluoroscopy possibility
. Fig. 17.13. Arms positioned with maximum approx. 50° abduction in pronation position
. Fig. 17.12. Arms positioned with maximum 90° abduction in supination position
17.2 · Upper arm
17
17.2.2 Prone position
. Figs. 17.14–17.16.
Indications
Dorsal access to the humerus for fractures, pseudarthrosis, posttraumatic misalignment, tumours, inflammation, nerve lesions.
Preparations
4
Arm positioning devices
4
Special head positioning cushion for prone position
4Thorax, pelvic and wedge cushion, padded roll
4
Small arm rest, X-ray protection, C-arm (poss. G-arm) in the theatre
4Remove Gilchrist bandage
4
Shaving in the area of the incision and preoperative skin cleansing Positioning
4
Standard operating table position 1, position 2 or universal operating table
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Transfer to the prepared operating table in the induction room
4Position both tables next to each other, with the prepared table lowered
4Place the patient in prone position on the padded cushion of the prepared
operating table and take him into the theatre
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
Position the head on the special head positioning cushion
4Position the infusion arm on the arm positioning device
4
Position the patient near to the edge of the table, until the injured/fractured arm hangs at the elbow over the edge of the small arm rest with the lower arm in a vertical position
4
Apply the neutral electrode and connect to the HF surgery device
4Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system
. Fig. 17.14. Prone position with small arm plate/upper arm plate
. Fig. 17.15. The distal joint is positioned lower than the proximal joint
. Fig. 17.16. Use of the image intensifier on the head side (here in anteropos- terior position) offers optimum scope for swivelling round
17.2 · Upper arm
17
17.3 Elbow
17.3.1 Supine position
. Figs. 17.17–17.20.
Indications
Lateral, medial, ventral and dorsal access to the elbow for fractures, posttrau- matic misalignment, floating cartilage, inflammation, arthrosis, arthrofibrosis, soft tissue lesions, nerve lesions and contractures.
Preparations
4
Arm positioning devices
4Remove Gilchrist bandage
4Large arm table
4
Shaving in the area of the incision and preoperative skin cleansing
4Apply a tourniquet in position
Positioning
4
Standard operating table position 1, position 2 or universal operating table with X-ray protection
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
Standard supine position, infusion arm is in abduction
4
1st arm table: remove the arm positioning device and fasten the large arm table to the rail of the back plate
4
Position the patient near to the edge of the table
4
Apply the neutral electrode and connect to the HF surgery device
4Connect the compressed air device to the tourniquet
4
Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system
. Fig. 17.17. Arm positioning on large arm table
. Fig. 17.18. 360° fluoroscopy possibility
. Fig. 17.20. Arms positioned with maximum approx. 50° abduction in pronation position
. Fig. 17.19. Arms positioned with maximum 90° abduction in supination position
17.3 · Elbow
17
17.3.2 Prone position
. Figs. 17.21–17.23.
Indications
Dorsal access to the elbow for fractures, posttraumatic misalignment, floating cartilage, inflammation, arthrosis, arthrofibrosis, soft tissue lesions, nerve lesions and contractures.
Preparations
4
Arm positioning devices
4
Special head positioning cushion for prone position, thorax, pelvic and wedge cushion, padded roll
4
Small arm rest, X-ray protection, C-arm (poss. G-arm) in the theatre
4Remove Gilchrist bandage
4
Shaving in the area of the incision and preoperative skin cleansing
4Apply a tourniquet in position
Positioning
4
Standard operating table position 1, position 2 or universal operating table
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Transfer to the prepared operating table in the induction room
4Position both tables next to each other, with the prepared table lowered
4Place the patient in prone position on the padded cushion of the prepared
operating table and take him into the theatre
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
Position the head on the special head positioning cushion
4Position the infusion arm on the arm positioning device
4
Position the patient near to the edge of the table, until the injured/fractured arm hangs at the elbow over the edge of the small arm rest with the lower arm in a vertical position
4
Apply the neutral electrode and connect to the HF surgery device
4Connect the compressed air device to the tourniquet
4
Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system
. Fig. 17.21. Prone position with small arm plate/upper arm plate
. Fig. 17.23. The small arm plate/upper arm plate should have a nar- row surface so that the arm can be bent
. Fig. 17.22. The distal joint is positioned lower than the proximal joint
17.3 · Elbow
17
17.4 Forearm and hand
17.4.1 Supine position
. Figs. 17.24–17.29.
Indications
Ventral, dorsal and dorsolateral access to the forearm, dorsal and palm access to the wrist and to the hand, access to the thumb and first finger for fractures, posttraumatic misalignment, pseudarthrosis, luxation, inflammation, arthro- sis, soft tissue lesions, nerve lesions, contractures, tumours, operations to ten- dons, synovial sheaths and carpal tunnel.
Preparations
4
Arm positioning devices
4Remove splints from extremity
4Large arm table
4
Shaving in the area of the incision and preoperative skin cleansing
4Apply a tourniquet in position
Positioning
4
Standard operating table position 1, position 2 or universal operating table with X-ray protection
4
Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices
4
Crosswise positioning of the operating table in the theatre
4
When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure
4
Standard supine position, infusion arm is spread out
4
Remove the arm positioning device and fit the large arm table to the side rail of the back plate
4
Position the patient near to the edge of the table
4
Apply the neutral electrode and connect to the HF surgery device
4Connect the compressed air device to the tourniquet
4
Arrange self-adhesive covers for preoperative skin disinfection
4Position the operating lights
4
Patient warming system
. Fig. 17.24. Arm positioning on large arm table
. Fig. 17.25. 360° fluoroscopy possibility
. Fig. 17.29. Operation scene . Fig. 17.28. The image intensifier is ready for use on the side opposite
the surgeon
. Fig. 17.27. Arms positioned with maximum approx. 50° abduction in pronation position
. Fig. 17.26. Arms positioned with maximum 90° abduction in supi- nation position
17.4 · Lower arm and hand
