Positioning

After the initial assessment of the patient is made, attention is turned to positioning. Proper body alignment is important for all these patients and requires a sound knowledge of operative procedure and body mechanics. Individual surgeons generally have specific directives for positioning, but general guidelines apply to all patients. The goal is optimal comfort and safety for the operated limb or area. The upper extremities should be held close to the body; elevation should be achieved without undue pressure on the elbow or shoulder. The lower extremities are in a neutral position, with support provided for the entire length, and heels are off the bed.

Elevation of operative limbs is usually indicated to increase venous return, reduce swelling, and promote comfort. In the elevation of a hand or arm, the hand must be higher than the heart and no pressure should be placed on the elbow. This position can be achieved with the use of a stockinette device for suspension on an intravenous (IV) pole. The stockinette is measured from the elbow to approximately 12 inches beyond the fingertips; a piece is cut double this length. That piece is then folded in half, with the elbow resting in the fold. With safety pins, the sides are closed around the limb to form a tube, while ensuring that the fingers are exposed (for assessment of neurovascular status). With the excess material, a knot is tied and suspended from the IV pole. The elbow should be properly supported. If a pillow is used for elevation, the arm should be allowed slight flexion for maximum comfort and provide additional support for the elbow and shoulder.

Lower extremity elevation is most effective if the toes are above the heart. If the limb is not in an immobilization device, it is kept in a position of extension. This position is achieved by elevating the foot of the bed rather than with the use of pillows. The entire length of the limb should be supported if pillows are used and the heels are kept off the bed.

Shoulder immobilization can be accomplished with a sling or shoulder immobilizer. An airplane splint (a padded and Velcro shoulder orthotic used to position the shoulder in various degrees of abduction; Fig. 37-1) may be applied for rotator cuff repairs and other involved humerus fractures and postoperative shoulder or arm surgery where shoulder position and elbow flexion control are desired. If a sling is used, the patient is instructed to keep the arm close to the chest, with the wrist and elbow supported. All shoulder immobilizers require special care and padding to areas where skin contacts skin.

FIG. 37-1 Airplane splint.

(From Coppard BM, Lohman H: Introduction to splinting: a clinical-reasoning and problem solving approach, ed 2, St. Louis, 2001, Mosby.)

The patient with a hip pinning is positioned with proper body alignment, and the legs are in a proper neutral position. Care is given to avoid stress to the operative area with exaggerated flexion or rotation. A pillow is placed between the knees during turning to prevent adduction and rotation.

For the patient with a posterior or lateral total hip replacement, proper body alignment is achieved with placement of an abduction pillow between the knees at all times (Box 37-1). Most important with these patients is to avoid flexion and adduction of the newly placed joint. There are four basic positions to be avoided after hip surgery: 1) no flexion of the hip past 90 degrees with respect to the axis of the body; 2) no abduction of the leg past the midline of the body; 3) no combined extension of the hip joint with external rotation of the lower extremity; and 4) no flexion with internal rotation. Use of the abduction pillow helps to prevent the patient from getting into positions that could cause dislocation. The patient who has had an anterior total hip replacement does not require dislocation precautions. Therefore there is no need for an abduction pillow, traction sling, or hip cushion to assist with positioning.¹

BOX 37-1 Surgical Approaches for Total Hip Arthroplasty

The approaches for total hip arthroplasty vary in the invasiveness of the hip musculature: (1) the posterior approach, (2) the lateral or transgluteal approach, (3) the anterolateral approach, and (4) the anterior approach.

1. The posterior approach (i.e., Kocher-Langenbeck approach) splits the gluteus maximus muscle and detaches the posterior external rotator muscles (i.e., the piriformis, obturator internus and externus, superior and inferior gemellus).

2. The lateral or transgluteal approach (i.e., Harding approach) splits the gluteus medius muscle and detaches the gluteus minimus and the anterior third of the gluteus medius muscles from the femur.

3. The anterolateral approach (i.e., Watson-Jones approach) is performed posterior to the tensor fascia lata and anterior to the gluteus medius and splits the hip deltoid muscle, which consists of the gluteus maximus and tensor fascia lata muscles.

4. The anterior approach (i.e., short Smith-Petersen and Hueter approach) does not split or detach muscles. This approach is performed over the tensor fascia lata, inside the tensor sheath, anterior and medial to the tensor fascia lata, and lateral to the sartorius and rectus femoris muscles.

(From Munro CA: The perioperative nurse’s role in table-enhanced anterior total hip arthroplasty, AORN J 90:54, 2009. Illustration by Kurt Jones.)

The perianesthesia nurse should also be familiar with various types of orthopedic equipment that may be used and that can affect positioning. Often, patients with total knee replacement and those with more extensive knee arthrotomy are placed in a continuous passive motion (CPM) machine. The purpose of CPM is to enhance the healing process by providing CPM to the joint, thus increasing circulation and movement. Traction may also be used with various patients to immobilize and align a specific area. The perianesthesia nurse is not usually involved in setting up the traction, but should be aware of some basic principles for maintenance: (1) the traction must be continuous, (2) the patient is centered in bed in good alignment to maintain the line of pull in line with the long bone, (3) weights should hang freely and not resting on the floor or bed, and (4) the pulley ropes should be in alignment and free of knots. One type of traction is depicted in Fig. 37-2.

FIG. 37-2 Russell skin traction (single) with overhead frame and trapeze.

Neurovascular assessment

Critical to the care of the patient for orthopedic surgery is assessment of the neurovascular status of the operative limb. Any alteration in blood flow to the extremity or nerve compression requires immediate intervention. Assessment is recommended every 30 minutes because problems can occur within 2 to 4 hours. Baseline neurovascular indicators should be noted in the admission nursing assessment. These indicators can be used to establish any deleterious effects from the surgery and to avoid the masking of potential complications. Both the affected and unaffected limbs are assessed.²

The hallmarks of neurovascular changes from constriction and circulatory embarrassment are pain, discoloration (skin that is pale or bluish), decreased mobility, coldness, diminished or absent pulses, altered capillary refilling, and swelling. Pain is common with patients for orthopedic surgery, and the approach to treatment must be individualized. Pain unrelieved with conventional methods, such as elevation and repositioning and the administration of opioids, must be assessed further. Color indicates circulatory compromise.² Cyanosis suggests venous obstruction; pallor suggests arterial obstruction. Mobility is assessed by determining the range of motion of the fingers or toes and strongly indicates neural compromise. Fingers are flexed, extended, spread, and wiggled. Toes should be dorsiflexed, plantarflexed, and wiggled. An inability to move the fingers or toes, pain on extension of the hand or foot, or coldness of the extremity is indicative of ischemia. Sensation is described as normal, hypesthetic (dulled), paresthetic, or anesthetic. Alteration in sensation suggests nerve compression or circulatory compromise. Limb perfusion is further assessed with the presence of peripheral pulses and capillary refilling. Capillary refilling is assessed with compression of the nail bed, which causes blanching; when the compression is released, color briskly returns. Compromise delays the filling time. With the development of pulse oximetry, a more reliable method of perfusion assessment is available. With placement of the oximeter sensor on a finger or toe of the affected limb, the pulsation is sensed and oxygen saturation is displayed. This method is more reflective of perfusion than capillary refilling and is valuable when pulses cannot be assessed because of the presence of a cast or dressing.

Care of immobilization devices (cast care)

Immediate assessment of the patient after orthopedic surgery in the PACU should include the type of immobilization device applied. The soft knee immobilizer should be checked for proper placement and closure, and the surgical dressing should be checked for drainage. For care that involves traction, refer to the previous section in this chapter on positioning.

The cast is a rigid immobilization device molded to the contours of the part to which it is applied. The cast has a dual purpose: immobilization in a specific position and provision of uniform pressure on the encased soft tissue. The cast should be inspected for visibility of fingers and toes for neurovascular assessment. If the cast is bivalved, the edges should be inspected for roughness to avoid discomfort and potential skin breakdown. When the patient arrives in the PACU, the cast is likely still wet, and special care must be taken to prevent indentations. A wet cast must be handled carefully with the palms of the hand to avoid pressure from fingertips. The cast should be supported on a pillow, and hard flat surfaces should be avoided. Improper handling and flat surfaces can cause indentations that can lead to the development of pressure sores. More frequently, a fiberglass cast is applied with quicker drying properties, but the same general principles still apply.² In general, a full cast may not be placed on a patient where wound drainage is expected (a temporary splint or cast would be used), but any drainage noted on the cast should be circled, and the time should be noted. This documentation can provide a guide for postoperative blood and fluid loss and can alert the nurse if the drainage appears to be excessive. Note that orthopedic wounds tend to ooze and may bleed more than other surgical wounds.

Wound care

All surgical dressings should be checked for drainage and closure. Patients with orthopedic surgery are highly susceptible to infection; therefore strict asepsis is required when changing dressings or handling drains. Drains may be placed in the wound to minimize blood accumulation and the possibility of infection. Care must be taken to attend these drains and maintain suction.

A patient with total joint replacement may commonly have a large amount of blood loss in the immediate postoperative period. This loss can be as great as 250 to 300 mL in the first hour. With advances in technology and the implementation of minimally invasive techniques, blood loss of even 150 mL in the first hour could be significant and may require surgeon notification. The retrieval of this blood for reinfusion (autotransfusion), when coupled with preoperative autologous blood donation, has substantially reduced the need for homologous transfusions. Autotransfusion is accomplished with the use of self-contained disposable systems that are designed for easy setup and safe use.

Range-of-motion exercises

Range-of-motion exercises can be initiated in the PACU as soon as the patient is alert and cooperative. Flexion, extension, and rotation of joints distal to the operative area assist in stimulating circulation and strengthening muscles. Quad tightening exercises, if permitted by the physician, may also be helpful. Prevention of venous stasis decreases the incidence rate of thromboembolism, and early movement of joints promotes healing and stabilization.

Observation for complications

Postoperative complications for the patient after orthopedic surgery include deep vein thrombosis, pulmonary embolism, fat embolism syndrome, compartment syndrome, shock, and urinary retention.

Deep vein thrombosis

Prevention of deep vein thrombosis (DVT) is a major concern for patients undergoing orthopedic surgery, especially total joint replacement.³ Other contributing risk factors include age, previous history of DVT or pulmonary embolism (PE), metastatic malignancy, smoking, estrogen or current pregnancy, vein disease, obesity, and genetics (Box 37-2). Thrombosis is the formation of a blood clot associated with three conditions outlined by Virchow in 1846: venous stasis, altered clotting mechanism, and altered vessel wall integrity.⁴ Immobilization and the insult of the surgical procedure place the orthopedic patient at high risk. DVT refers to the formation of a thrombus within the deep vein, typically the thigh or calf. In reports of total hip arthroplasty before routine prophylaxis, venous thrombosis occurred after total hip replacement in 50% of patients, and fatal pulmonary emboli occurred in 2%.³ Immobilization impairs the leg muscle action needed to move the blood sufficiently, and the surgical procedure injures vessel walls that activate and alter clotting mechanisms. An inflammation process begins within the vessel wall and leads to deep vein thrombosis. The patient usually has pain and tenderness. Signs include swelling and sometimes localized redness. Palpation of the calf reveals firmness or tension of the muscle. A positive Homans sign may be seen, although a positive sign does not accurately diagnose a DVT alone.⁵ DVT can be difficult to diagnose. Diagnostic tests such as venography, magnetic resonance imaging, or Doppler ultrasound may be indicated.

BOX 37-2 Risk Factors for Venous Thromboembolic Disease

Clinical Risk Factors	Hemostatic Abnormalities (Hypercoagulable States)
Advanced age	Antithrombin III deficiency
Fracture of pelvis, hip, femur, or tibia	Protein C deficiency
Paralysis or prolonged immobility	Protein S deficiency
Prior venous thromboembolic disease	Dysfibrinogenemia
Operation involving abdomen, pelvis, or lower extremities	Lupus anticoagulant and antiphospholipid antibodies
Obesity	Myeloproliferative disorder
Congestive heart failure	Heparin-induced thrombocytopenia
Myocardial infarction	Disorders of plasminogen and plasminogen activation
Stroke

Adapted from Anderson FA, Spencer FA: Risk factors for venous thromboembolism, Circulation 107:S19, 2003; Lieberman JR, Hsu WK: Current concepts review: prevention of venous thromboembolic disease after total hip and knee arthroplasty, J Bone Joint Surg 87A:2097, 2005.

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