CO N T I N U ING EDUCAT ION
Back to Basics: Orthopedic Positioning
2.2 www.aornjournal.org/content/cme
Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN
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PURPOSE/GOAL
To provide the learner with knowledge of best practic-
es ­related to safely positioning patients for orthopedic
­surgery.
OBJECTIVES
1. Discuss common areas of concern that relate to
perioperative best practices.
2. Discuss best practices that could enhance safety in the
perioperative area.
3. Describe implementation of evidence-based practice in
relation to perioperative nursing care.
http://doi.org/10.1002/aorn.12071
© AORN, Inc, 2018
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AORN is accredited with distinction as a provider of
continuing nursing education by the American Nurses
­Credentialing Center’s Commission on Accreditation.
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tification, as well as other CE requirements.
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tivity for relicensure.
CONFLICT-­OF-­INTEREST DISCLOSURES
Lisa Spruce, DNP, RN, CNS-­CP, CNOR, ACNS, ACNP, FAAN,
has no declared affiliation that could be perceived as posing a
potential conflict of interest in the publication of this article.
The behavioral objectives for this program were created by
Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-­BC, director,
Perioperative Education. Ms Van Anderson and Ms Bakewell
have no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.
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this article.
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AORN recognizes these activities as CE for RNs. This
recognition does not imply that AORN or the American
­Nurses Credentialing Center approves or endorses prod-
ucts mentioned in the activity.
AORN Journal  355  
 CLINICAL

Back to Basics: Orthopedic Positioning

2.2 www.aornjournal.org/content/cme

Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN

ABSTRACT
Orthopedic patients have unique needs related to safe positioning for surgery and often require the use of special-
ized tables and equipment. It can be challenging to position patients securely using specialty orthopedic positioning
equipment while maintaining proper body alignment and preventing injury. Positioning patients is a team effort
that involves the perioperative nurse, surgeon, anesthesia professional, and other personnel as needed (eg, first
assistants, surgical technologists). This Back to Basics article addresses some of the challenges that perioperative
RNs may face when positioning a patient for orthopedic surgery and offers guidance on how to position orthopedic
patients safely in the supine, Fowler and semi-­Fowler, hemilithotomy, lateral, and prone positions.

Key words: patient positioning, orthopedic surgery, orthopedic positioning, fracture table, compartment syndrome.

I n the 2014 report Annual Incidence of Common

­Musculoskeletal Procedures and Treatment, the American
Academy of Orthopedic Surgeons presented national
total joint replacement data from 2000 to 2011. According
to the report, there were an estimated 645,062 total knee
patients that perioperative nurses can refer to when seek-
ing guidance on positioning patients for surgery. This Back to
Basics article focuses on basic positioning considerations for
patients undergoing orthopedic procedures.

arthroplasties, 306,600 total hip arthroplasties, 29,414
total shoulder arthroplasties, and 465,070 spinal fusions
performed in the United States in 2011.1 These data indi-
cate a 128% increase in total knee arthroplasties, an 86%
increase in total hip arthroplasties, a 307% increase in to-
tal shoulder arthroplasties, and a 121% increase in spinal
fusions compared with incidence data from 2000.1 The
aging Baby Boomer generation likely will continue to fuel
the increasing demand for orthopedic procedures. Given
the high number of orthopedic procedures being per-
formed per year, it is likely that most perioperative nurses
will care for patients undergoing orthopedic procedures
during their career.
There are many important care considerations for patients
undergoing orthopedic procedures. One of the most import-
ant tasks for the perioperative team is positioning these pa-
tients safely for surgery. AORN’s “Guideline for positioning
the patient”2 is a comprehensive resource for positioning
The goals of patient positioning include
• providing exposure of the surgical site;
• maintaining the patient’s comfort and privacy;
• providing access to intravenous (IV) lines and monitoring
equipment;
• allowing for optimal ventilation by maintaining a patent
airway and avoiding constriction or pressure on the chest
or abdomen;
• maintaining circulation and protecting muscles, nerves,
bony prominences, joints, skin, and vital organs from ­injury;
• observing and protecting fingers, toes, and genitals; and
• stabilizing the patient to prevent unintended shifting or
movement.2(p673)
Positioning patients is a team effort that involves the
perioperative nurse, surgeon, anesthesia professional, and
other personnel as needed (eg, first assistants, surgical

http://doi.org/10.1002/aorn.12071
© AORN, Inc, 2018
356  AORN Journal 
March 2018, Vol. 107, No. 3
Figure 1.  The supine position. Reprinted with permission from the “Guideline for positioning the patient.” In:
Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017. Illustration by Kurt Jones.
technologists).2 It is perioperative team members’ respon-
sibility to advocate for the patient and to maintain the
patient’s dignity and privacy throughout the positioning
process.2 All members of the perioperative team who are
involved in positioning the patient are responsible for
• assessing and evaluating the patient’s risk for injury;
• anticipating the extent of exposure that is necessary for
surgical access;
• gathering and properly using positioning equipment
and devices;
• monitoring the patient during the procedure;
• ensuring proper body mechanics and alignment during
patient positioning;
• respecting the patient’s physical limitations that may
affect positioning;
• implementing interventions to provide for the patient’s
comfort and safety; and
• protecting the patient’s circulatory, respiratory, muscu-
loskeletal, neurological, and integumentary structures.2
Failure to position the patient appropriately and safely
may be viewed as a failure to meet the duty of care owed
to the patient and could be deemed negligence, following
the doctrine of res ipsa loquitur (the thing speaks for itself),
in which there is an assumption that the event causing the
injury was under the control of the health care provider.2
Therefore, it is of the utmost importance to follow the
guidance found in AORN’s “Guideline for positioning the
patient” to protect patients and health care providers.
HOW-­TO GUIDE
There are multiple positions that may be necessary for pa-
tients undergoing orthopedic surgery. Depending on the
Back to Basics: Orthopedic Positioning
surgery being performed, patients may be placed in the
supine, Fowler or semi-­Fowler, hemilithotomy, lateral, or
prone position for orthopedic procedures.
Supine Position
Patients undergoing orthopedic procedures that require
access to the front of the body, such as patients with
multiple injuries that require simultaneous procedures or
those that require intramedullary nailing of tibial fractures,
may be placed in the supine position (Figure 1). In a pro-
spective randomized controlled trial of 85 patients, McK-
ee et al3 compared intramedullary nailing of tibial fractures
with manual traction with patients in the supine position
to ­patients placed on a fracture table. The researchers
found that patients in the supine position had significantly
reduced positioning time, and that this position allowed
simultaneous procedures to be performed.
The supine position places extra pressure on the skin over
the back of the head, scapula, elbows, sacrum, coccyx, and
heels.2 AORN’s “Guideline for positioning the patient”2
offers recommendations for positioning practices to de-
crease pressure on these areas that are prone to pressure
injury. When positioning the patient supine, the patient’s
arms should be
• tucked at the sides with a draw sheet;
• secured at the sides with arm guards;
• flexed and secured across the body; or
• extended on arm boards, abducted less than 90 de-
grees.2
When tucking and securing the patient’s arms with a draw
sheet, the arms should be in a neutral position with the
palms facing the body and the elbows not hyperextended.
AORN Journal  357  
Spruce
Figure 2.  When tucking the patient’s arms, the draw sheet should be tucked between the patient’s body and
the OR mattress. Reprinted with permission from the “Guideline for positioning the patient.” In: Guidelines for
Perioperative Practice. Denver, CO: AORN, Inc; 2017. Illustration by Kurt Jones.
The team members positioning the patient should pull the
draw sheet up between the patient’s body and arm, place
the sheet over the patient’s arm, and tuck the sheet be-
tween the patient and the OR bed mattress (Figure 2). The
sheet should be tight enough to secure the arm but not so
tight that it becomes a source of pressure, and should ex-
tend from the mid-­upper arm to the fingertips.2 These in-
terventions prevent the patient’s arms from falling off the
mattress and resting on the metal portion of the OR bed.2
Lateral rotation of the patient’s head can occur in the su-
pine position and lead to nerve injuries, including dam-
age to the ulnar nerve caused by increased pressure and
stretching of the brachial plexus.4 The risk for brachial
plexus injury is also increased when the patient’s arm is
abducted more than 90 degrees.2 Therefore, it is import-
ant to maintain neutral alignment of the patient’s head
and arms.
Positioning interventions for the lower body in the supine
position include
• supporting the patient’s lumbosacral area with a pillow
or pad,
• flexing the patient’s knees 5 to 10 degrees (eg, by plac-
ing a soft pillow under the knees),
• placing a safety strap approximately two inches above
the patient’s knees,
• keeping the patient’s ankles uncrossed, and
• elevating the patient’s heels off the underlying surface.2
It is important to redistribute the pressure on a patient’s
heels by using a heel-­suspension device that is designed
358  AORN Journal 
March 2018, Vol. 107, No. 3
not only to elevate the heel, but also to distribute the
weight of the patient’s leg along the calf. Another way to
redistribute pressure on the heels is to elevate and sup-
port the patient’s calves with a pressure-­redistributing
surface that is wide enough to accommodate the exter-
nally rotated malleolus.2
Fowler and Semi-­Fowler Positions
A variation of the supine position is the Fowler posi-
tion (ie, sitting position) or the semi-­Fowler position
(ie, semi-­sitting or beach chair position) (Figure 3). This
position is used for orthopedic procedures that require
access to the shoulder (eg, shoulder arthroscopy). One
advantage of this position for shoulder surgery is that
if the procedure is being performed laparoscopically, it
gives the surgeon an option to convert the procedure
to an anterior open approach more easily than if the pa-
tient was positioned laterally.5 Cerebral hypoperfusion
is a serious consequence of the Fowler or semi-­Fowler
positions; therefore, the degree of patient head eleva-
tion should be minimized as much as possible.2,6 When
patients experience cerebral hypoperfusion, the brain
is at risk for ischemic injury, which can cause cognitive
decline, organ injury, stroke, and death.7 It is also im-
portant to maintain the patient’s head in a neutral posi-
tion without excessive extension, flexion, or rotation.2
Hyperextension of the patient’s neck could result in a
spinal cord injury,8 while rotation of the patient’s neck
could lead to neuropathy from compression or stretch-
ing of the glossopharyngeal, vagus, and hypoglossal
nerves.9 Other complications that may result from
­improper head positioning include hypoglossal nerve
palsy and stroke.2
March 2018, Vol. 107, No. 3
Figure 3.  The Fowler (ie, sitting) position. Reprinted with permission from AORN, Inc; 2017. Illustration by Kurt
Jones.
Perioperative team members should always be aware of
and monitor the patient’s head position during the pro-
cedure and any positioning activities and take corrective
action as soon as a safety concern is identified.2 Perioper-
ative team members should not use a horseshoe-­shaped
head positioner if possible because of the risk of injury to
the lesser occipital or greater auricular nerve.2 Other po-
sitioning interventions for patients in the Fowler or semi-­
Fowler position include
• flexing and securing the patient’s arms or nonoperative
arm across the body,
• positioning the operative arm to either be held by the
surgeon or assistant or be supported with an arm-posi-
tioning device,
• minimizing extension and external rotation of the oper-
ative arm,
• placing padding under the patient’s buttocks,
• flexing the patient’s knees to 30 degrees, and
• positioning the safety strap across the patient’s thighs.
The perioperative nurse should apply sequential ­com-­
pression devices to limit venous pooling. The sitting
position should not be used for patients who have
­ventriculoperitoneal shunts if possible. When positioning
Back to Basics: Orthopedic Positioning
the obese patient, the abdominal pannus should not rest
on the thighs.2
Hemilithotomy Position
A common position used for patients who are undergoing
a fracture fixation is the hemilithotomy position (Figure 4).
This is a variation of the lithotomy position in which the pa-
tient is placed on a fracture table with his or her nonoper-
ative leg positioned in standard lithotomy and the opera-
tive leg straightened and placed in traction. The danger of
placing a patient’s nonoperative leg in this position is the
risk of developing well-­leg compartment syndrome.2 Com-
partment syndrome can occur when pressure exerted on a
muscle builds to a point at which blood flow to the muscle is
decreased, preventing oxygen and nourishment to the mus-
cle. If pressure is not relieved, permanent damage to the
muscle or tissue death can occur.10
AORN recommends against using the hemilithotomy
2
position if possible.2 Tan et al11 studied 10 patients un-
dergoing intramedullary nailing while in the hemilithot-
omy position and found that the calf compartment pres-
sure in the nonoperative legs increased by more than 18
mm Hg, and the pressure remained elevated until the
leg was taken down. This increase in pressure was the
AORN Journal  359  
Spruce
Figure 4.  The hemilithotomy position. Reprinted with permission from AORN, Inc; 2017. Illustration by Kurt
Jones.
direct result of mechanical compression from the leg
holder. In addition to compartment syndrome, Hsu et
al12 reported a case of nonoperative-­leg foot drop in a
patient in the hemilithotomy position. The case involved
a 28-­year-­old female patient who sustained a commi-
nuted spiral fracture of her right femur during a motor
vehicle accident. Her nonoperative leg was placed in 80
degrees of hip flexion, 30 degrees of abduction, and 105
degrees of knee flexion and was held in a boot without
leg holders or knee straps. Postoperatively, the patient
complained of severe numbness in her foot and diffi-
culty moving. She was diagnosed with common pero-
neal nerve palsy, was fitted with an orthotic, and under-
went physical therapy. She made a complete recovery
at three months. The authors concluded that the injury
occurred because of compression from the positioning
of the nonoperative leg and recommended releasing the
extremities at regular intervals or implementing alterna-
tive surgical approaches if personnel expect procedures
to be lengthy.
Patients are frequently placed on a fracture or traction ta-
ble for fixation of hip fractures or for hip arthroplasty or
hip arthroscopy. In addition to the hemilithotomy position,
patients can be placed in the supine, lateral, or prone posi-
tion on a fracture table. Bonnaig et al4 offer some consid-
erations when placing patients on a fracture table:
• patients should be anesthetized on a gurney or bed be-
fore being moved onto the fracture table,
• the perineal post should be well padded, and
• the patient’s feet should be padded.
360  AORN Journal 
March 2018, Vol. 107, No. 3
The authors acknowledge the potential risks of the he-
milithotomy position and offer strategies for decreasing
risk, including increasing doses of muscle relaxants, making
sure that the traction is released when no longer needed,
and periodically releasing the traction during the surgery.4
Lateral Position
Another position used for orthopedic procedures is the
lateral position (Figure  5), which is commonly used for
procedures that involve the hip or shoulder. In this posi-
tion, the patient is placed on the nonoperative side (eg, for
a left total hip arthroplasty, the patient would be placed
in the right lateral position).2 Patients are at risk for injury
because of the pressure exerted on the dependent side.
At-­risk areas are the ear, elbow, shoulder, iliac crest, hip,
knee, and ankle. This position also puts patients at risk for
compartment syndrome and rhabdomyolysis.2
Wijesuriya et al13 reported a case of a 20-­year-­old male
patient who fell from a ladder and sustained an intra-­
articular fracture of the right distal humerus and a stable
undisplaced fracture of the right distal fibula. The patient
was positioned in the left lateral position on a fracture ta-
ble with pelvic support and the right arm was free over an
L-­shaped bar without use of a tourniquet. The left fore-
arm was secured, flexed at the elbow, padded, and posi-
tioned so that the hand was adjacent to the patient’s face.
The patient was a bodybuilder, and because of the large
size of the triceps on the operative arm, the surgery was
technically demanding and lasted 4.5 hours. After awak-
ening, the patient complained of excruciating pain in his
March 2018, Vol. 107, No. 3
Figure 5.  The lateral position. Reprinted with permission from AORN, Inc; 2017. Illustration by Kurt Jones.
left arm, which he had been lying on throughout the sur-
gery. Clinical examination revealed a hugely swollen, red,
and extremely tender deltoid area. The patient could not
abduct his arm because of the pain. The patient was diag-
nosed with compartment syndrome and was immediately
transferred back to the OR for a fasciotomy. The patient
subsequently underwent plastic surgery for the triceps
wound associated with the fracture; after six months, he
was completely healed and resumed work. The authors
noted that the patient had been abusing systemic anabol-
ic steroids for bodybuilding, which may have put him at
­additional risk of developing compartment syndrome.
Perioperative team members also should be aware that
prolonged surgery in the lateral position can lead to vas-
cular congestion and hypoventilation in the dependent
lung.2 Therefore, patients who have preexisting pulmonary
or cardiac disease may not tolerate this position. AORN’s
“Guideline for positioning the patient” recommends that
perioperative team members adhere to the following for
patients in the lateral position.
• Keep patients in the lateral position for the shortest pe-
riod of time possible.
• Reposition patients at facility-established intervals to
decrease the risk of compartment syndrome.
• Place a pillow or head positioner under the patient’s
head.
• Monitor the dependent ear to make sure it is not fold-
ed.
• Position the patient’s arms on two levels, parallel arm
boards with one arm on each board and both abducted
less than 90 degrees.
Back to Basics: Orthopedic Positioning
• Place a roll under the patient’s dependent thorax, distal
to the axillary fold at the level of the seventh to ninth
rib, using a device designed for this use; do not use a
rolled sheet or towel.
• Verify bilateral radial pulses after placing the roll.
• Maintain the patient’s physiological spinal alignment.
• Place a safety restraint across the patient’s hips.
• Flex the patient’s dependent leg at the hip and knee
while keeping the upper leg straight and a pillow placed
between the legs.
• Pad the dependent knee, foot, and ankle.2
Prone Position
The prone surgical position (Figure 6) is most often used
for procedures requiring a posterior approach; these are
most commonly spine surgeries. This position presents
some potentially severe complications for the patient.
Placing a patient prone puts pressure on the abdomen,
which can reduce blood flow through the inferior vena
cava, causing engorgement of the paravertebral and epi-
dural veins and leading to increased bleeding in the surgi-
cal field.14 Coupled with a decrease in blood pressure and
hypovolemia, this can cause decreased perfusion to major
organs and increase the risk of acute kidney injury.14
A devastating complication of prone positioning is post-
operative vision loss (POVL) caused by ischemic optic
neuropathy and central retinal artery occlusion.15 Most
cases of POVL are associated with prolonged spine pro-
cedures under general anesthesia—posterior lumbar fu-
sions and correction of scoliosis are associated with the
highest rates of POVL.15 Ischemic optic neuropathy is
AORN Journal  361  
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Figure 6.  The prone position. Reprinted with permission from AORN, Inc; 2017. Illustration by Kurt Jones.
most commonly related to a combination of blood loss,
hypotension, and an increase in orbital venous pressure.14
The prone and Trendelenburg positions can raise orbit-
al pressure, which causes a decrease in tissue perfusion
of the eye.14 To decrease the risk of POVL for patients in
the prone position, DePasse et al14 recommend placing
patients in some degree of reverse Trendelenburg, pre-
venting pressure on the patient’s face, maintaining blood
pressure, performing close invasive monitoring, and stag-
ing procedures to limit blood loss and decrease the dura-
tion of anesthesia.
AORN’s “Guideline for positioning the patient” recom-
mends that perioperative team members adhere to the
following when positioning the patient in the prone­
position.
• Place the patient in the prone positon for the shortest
time possible.
• Place the patient’s head in a neutral position.
• Place the patient’s face in a face positioner to protect
the forehead, eyes, and chin.
• Monitor the patient’s eyes to verify that there is no di-
rect pressure on the eye throughout the procedure.
• Tuck the patient’s arms at the sides with a draw sheet,
secure the arms at the sides with arm guards, place the
arms on arm boards positioned parallel to the OR bed,
or place the arms on an arm rest with adjustment joints
designed for that purpose.
• Position the patient on two chest supports that extend
from the clavicle to the iliac crest and make sure that
full lung and abdominal expansion are allowed.
• Make sure the patient’s breasts, abdomen, and genitals
are free from torsion or pressure.
362  AORN Journal 
March 2018, Vol. 107, No. 3
• Pad the patient’s knees.
• Elevate the patient’s toes off the bed by placing pad-
ding under the shins.
• Check the patient’s pedal pulses after positioning the
patient in the knee-chest position.
• Have a gurney readily available to reposition the pa-
tient rapidly from prone to supine for cardiopulmonary
resuscitation if needed.2
BENEFIT
Positioning the patient for orthopedic surgery is one of
the most important tasks for the orthopedic perioperative
team. Performing patient positioning may require lifting,
pushing, or pulling motions, and therefore presents a high
risk for musculoskeletal injury to the lower back or shoul-
ders of the perioperative team members who perform
these tasks. Safe positioning practices can therefore help
prevent injury to both patients and team members.
STRATEGIES FOR SUCCESS
To achieve a successful positioning outcome, periopera-
tive RNs should first conduct an assessment to identify
factors that may put the patient at increased risk for posi-
tioning injury.2 For patients undergoing orthopedic proce-
dures, this assessment should include the
• type of procedure;
• estimated length of the procedure;
• ability of the patient to tolerate the planned position;
• amount of surgical exposure required;
• ability of the anesthesia professional to access the pa-
tient; and
March 2018, Vol. 107, No. 3 Back to Basics: Orthopedic Positioning

Key Takeaways
 Orthopedic patients have unique positioning needs and perioperative team members must be aware of best
practices for positioning these patients to prevent patient injury.
 Effective patient positioning involves providing proper surgical site exposure; maintaining the patient’s com-
fort and safety; maintaining IV lines, airway patency, and ventilation; protecting the patient from bodily inju-
ry; and providing stability to prevent unintended movement during the procedure.
 Patients undergoing orthopedic surgery may be placed in the supine, Fowler or semi-Fowler, hemilithot-
omy, lateral, or prone position. Each of these positions carry unique risks of injury to the patient (eg, nerve
injuries, pressure injuries, compartment syndrome) and perioperative team members should understand
positioning best practices to prevent these injuries.
 Perioperative team members also should understand how to use any specialized orthopedic equipment (eg,
fracture tables) that may be necessary when positioning patients for orthopedic procedures.

• desired position for the procedure, potential change
of  position, and positioning devices or equipment
­needed.2
Orthopedic patients often require specialized tables
and equipment for positioning. Perioperative RNs
should make sure that the equipment or tables needed
for the procedure are readily available, set up correctly,
and verified with the surgeon before the patient enters
the room. Additionally, perioperative nurses should in-
spect the equipment to make sure it is working proper-
ly, clean, and ready for patient use.2 AORN’s “Guideline
for positioning the patient” recommends the following
strategies for success when positioning patients in all
positions.
• Avoid extreme lateral rotation of the patient’s head.
• Reposition the patient’s head to reduce pressure during
the procedure.
• Protect the patient’s eyes by taping them closed using
transparent dressings, lubricating the eyes, or placing
goggles if the patient is not in the prone position.
• After positioning the patient, the anesthesia profes-
sional should check the airway.
• Monitor the location of patient’s hands, fingers, toes,
feet, and genitals.
• Assess the patient’s pulses after securing safety straps
and monitoring devices.
• Position patients with spinal cord lesions in such a way
that there is no direct pressure on the lesion.
• Monitor the patient’s position proactively throughout
the procedure.
• Make sure there are no devices or equipment resting
on the patient.
• Make sure that scrubbed personnel do not lean against
the patient.2
Neurophysiological monitoring is frequently used in or-
thopedic patients to monitor the function of the spi-
nal cord and can be used to identify positioning inju-
ries.2 Peripheral nerves in the upper extremities or the
brachial plexus can become stretched, compressed,
entrapped, or ischemic during positioning. Neurophys-
iological monitoring also may be used to monitor and
detect changes in the electrophysiological conduction
of the nerves and allows for repositioning before the
injury becomes irreversible.

• Do not hyperextend the patient’s neck for prolonged

periods.
• Do not let the patient’s body come into contact with
the metal portions of the OR bed.
• Do not let the patient’s extremities or hands drop be-
low the level of the OR bed.
WRAP-­UP
Correctly positioning the orthopedic patient is extremely
important to prevent injury and to make sure patients are
not harmed while receiving care that is intended to make
them better. Failing to meet the duty of care owed to pa-

AORN Journal  363  
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Resources
AORN. Safely Positioning the Surgical Patient
[DVD]. Woodbury, CT: Ciné-­Med, Inc; 2010.
Clinical FAQs: positioning the patient. AORN.
http://www.aorn.org/guidelines/clinical-resources/
clinical-faqs/positioning-the-patient. Accessed
November 1, 2017.
Guideline Essentials: positioning the patient.
AORN. https://www.aorn.org/essentials/positioning-
the-patient. Accessed November 1, 2017.
Guideline implementation topics: positioning the
patient. AORN. https://www.aorn.org/guidelines/
guideline-implementation-topics/patient-care/
positioning-the-patient. Accessed November 1,
2017.
Prevention of Perioperative Pressure Injury Tool
Kit. AORN. http://www.aorn.org/guidelines/
clinical-resources/tool-kits/prevention-
of-perioperative-pressure-injury-tool-kit.
Accessed November 1, 2017.
tients may result in not only injury to the patient, but may
be viewed as negligence on the part of the perioperative
team.2 When there is a positioning injury, the doctrine of
res ipsa loquitur may be deemed applicable and the inju-
ry perceived as under the control of the perioperative
team member (ie, the injury would not have occurred if
the perioperative team had provided proper care to the
patient).2 Therefore, it is important to patients and to
perioperative team members to implement positioning in-
terventions to prevent injury to patients and to document
the care provided.2
REFERENCES
1. AAOS Department of Research & Scientific
Affairs, American Academy of Orthopaedic Surgeons.
Annual Incidence of Common Musculoskeletal
­Procedures and Treatment. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2014. https://
www.aaos.org/research/stats/CommonProcedures
Treatments-March2014.pdf. Accessed November 1,
2017.
364  AORN Journal 
March 2018, Vol. 107, No. 3
2. Guideline for positioning the patient. In: Guidelines
for Perioperative Practice. Denver, CO: AORN, Inc;
2018:673‐744.
3. McKee MD, Schemitsch EH, Waddell JP, Yoo D. A
prospective, randomized clinical trial comparing
tibial nailing using fracture table traction versus
manual traction. J Orthop Trauma. 1999;13(7):
463‐469.
4. Bonnaig N, Dailey S, Archdeacon M. Proper pa-
tient positioning and complication prevention
in orthopaedic surgery. J Bone Joint Surg Am.
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5. Li X, Eichinger JK, Hartshorn T, Zhou H, Matzkin EG,
Warner JP. A comparison of the lateral decubitus
and beach-­chair positions for shoulder surgery: ad-
vantages and complications. J Am Acad Orthop Surg.
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Freehill MT. Basic shoulder arthroscopy: beach chair
patient positioning. Arthrosc Tech. 2016;5(4):e731‐
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7. Meex I, Genbrugge C, De Deyne C, Jans F. Cere-
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11‐17.
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9. Cogan A, Boyer P, Soubeyrand M, Hamida FB,
Vannier JL, Massin P. Cranial nerves neurapraxia
after shoulder arthroscopy in beach chair position.
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March 2018, Vol. 107, No. 3 Back to Basics: Orthopedic Positioning

13. Wijesuriya JD, Cowling PD, Izod C, Burton DJC.
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Lisa Spruce, DNP, RN, CNS-­CP, CNOR, ACNS, ACNP,
FAAN, is the director of Evidence-­Based Perioperative
Practice at AORN, Inc, Denver, CO. Dr Spruce has no de-
clared affiliation that could be perceived as posing a potential
conflict of interest in the publication of this article.

AORN CONTINUING EDUCATION FOR INDIVIDUALS

www.aorn.org/education/individuals/continuing-education
AORN can help you keep up with the latest perioperative practices to maintain your
license or certification requirements. Earn contact hours through AORN Journal
continuing education (CE) articles, prerecorded webinars, tool kits, and online courses.

AORN Journal CE articles cover a variety of

perioperative topics that can help you prepare
for recertification, renew your license, or just stay
up-to-date to improve your own practice. AORN
members receive free access to Journal CE.

AORN webinars present the latest clinical and

managerial issues, perioperative news, and best
practices to promote safety and optimal outcomes
for patients undergoing operative and other
invasive procedures.

AORN tool kits address critical patient safety

issues and help perioperative professionals
implement evidence-based practices. Each tool
kit contains a wealth of resources, including
customizable policies and procedures, education
slideshows, videos, posters, guides, and references.

AORN online courses are designed to educate perioperative nurses on a variety of

topics that go beyond the standards of Periop 101. Further your education online with
topics that are essential to promoting safety and optimal outcomes for patients, such
as ambulatory infection prevention, safe administration of moderate sedation, and
pre- and postoperative care in the ambulatory surgery center.

AORN Journal  365  
 E XA M I N AT I ON

Continuing Education
Back to Basics: Orthopedic Positioning
2.2 www.aornjournal.org/content/cme

PURPOSE/GOAL
To provide the learner with knowledge of best practices related to safely positioning patients for orthopedic surgery.

OBJECTIVES
1. Discuss common areas of concern that relate to perioperative best practices.
2. Discuss best practices that could enhance safety in the perioperative area.
3. Describe implementation of evidence-based practice in relation to perioperative nursing care.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit,
you must complete the online Examination and Learner Evaluation at http://www.aornjournal.org/content/cme.

QUESTIONS
1. The type of joint procedure that the American
Academy of Orthopedic Surgeons reported to be the
most commonly performed in 2011 was
a. total hip arthroplasty.
b. total shoulder arthroplasty.
c. total knee arthroplasty.
d. spinal fusion.
2. All perioperative team members who are involved in
positioning the patient are responsible for
1. ensuring proper body mechanics during patient
positioning.
2. gathering and properly using positioning equip-
ment and devices.
3. assessing and evaluating the patient’s risk for
injury.
4. respecting the patient’s physical limitations that
may affect positioning.
5. anticipating the extent of exposure that is neces-
sary for surgical access.
6. implementing interventions to provide for the pa-
tient’s comfort and safety.
a. 1, 3, and 5 b. 2, 4, and 6
c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
3. When positioning the patient supine, the patient’s arms
should always be tucked at the sides with a draw sheet.
a. true b. false
4. ______________________________ is a serious consequence of the
Fowler or semi-Fowler positions; therefore, the degree
of patient head elevation should be minimized as
much as possible.
a. Cerebral hypoperfusion b. Brain aneurysm
c. Peroneal nerve damage d. Subdural hematoma
5. Perioperative RNs should conduct an assessment to
identify factors that may put the patient at increased
risk for positioning injury. For orthopedic procedures,
this assessment should include the
1. amount of surgical exposure required.
2. estimated length of the procedure.
3. postoperative discharge plan for the patient.
4. type of procedure.
5. ability of the anesthesia professional to access the pa-
tient.
a. 4 and 5 b. 1, 2, and 3
c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5

http://doi.org/10.1002/aorn.12071
© AORN, Inc, 2018
366  AORN Journal 
 L EA R N ER E VALUAT ION
Continuing Education
Back to Basics: Orthopedic Positioning
2.2 www.aornjournal.org/content/cme
T his evaluation is used to determine the extent
to which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing edu-
cation credit, you must complete the online Examination
and Learner Evaluation at http://www.aornjournal.org/
content/cme. Rate the items as described below.
OBJECTIVES
To what extent were the following objectives of this con-
tinuing education program achieved?
  1. Discuss common areas of concern that relate to
perioperative best practices.
Low 1. 2. 3. 4. 5. High
  2. Discuss best practices that could enhance safety in
the perioperative area.
Low 1. 2. 3. 4. 5. High
  3. Describe implementation of evidence-based practice
in relation to perioperative nursing care.
Low 1. 2. 3. 4. 5. High
CONTENT
  4. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
  5. To what extent were your individual objectives met?
Low 1. 2. 3. 4. 5. High
http://doi.org/10.1002/aorn.12071
© AORN, Inc, 2018
  6. Will you be able to use the information from this
article in your work setting?
1. Yes 2. No
  7. Will you change your practice as a result of reading
this article? (If yes, answer question #7A. If no,
answer question #7B.)
7A. How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding why
change is needed
2. I will work with management to change/
implement a policy and procedure
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
change
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice
5. Other: _______________________________________________
7B. If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice
2. I do not have enough time to teach others about
the purpose of the needed change
3. I do not have management support to make a
change
4. Other: _______________________________________________
AORN Journal  367