Campbell's Operative Orthopaedics, 11th Edition

4810 Pages·2007·387.25 MB·English

In Memory of
Rocco A. Calandruccio Peter G. Carnesale Marcus J. Stewart
1923–2007 1937–2006 1911–2007
Since the last edition of this text, we have been saddened by the loss of three of our
colleagues, friends, and mentors. Each of these outstanding orthopaedic surgeons was a
leader, innovator, teacher, and role model, and we have valued their wisdom and
experience, which they so generously shared with us personally and with so many
others through their contributions to several editions of Campbell’s Operative Orthopaedics.
We all will miss their advice and counsel and their dedication to our profession.
Dedication to
Campbell Foundation personnel
whose skills and dedication
make this work a reality
Kay Daugherty, Medical Editor
Linda Jones, Medical Editor
Barry Burns, Graphic Artist and Videographer
Joan Crowson, Librarian
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Contributors
Frederick M. Azar, MD Andrew H. Crenshaw, Jr., MD Raymond J. Gardocki, MD
Professor and Residency Program Associate Professor Instructor
Director Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Director, Sports Medicine Fellowship University of Tennessee–Campbell University of Tennessee–Campbell
Department of Orthopaedic Surgery Clinic Clinic
University of Tennessee–Campbell Memphis, Tennessee Memphis, Tennessee
Clinic
Memphis, Tennessee John R. Crockarell, Jr., MD James L. Guyton, MD
Associate Professor Assistant Professor
James H. Beaty, MD Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Professor, Department of Orthopaedic University of Tennessee–Campbell University of Tennessee–Campbell
Surgery Clinic Clinic
University of Tennessee–Campbell Memphis, Tennessee Memphis, Tennessee
Clinic
Chief of Staff, Campbell Clinic Patrick M. Curlee, MD James W. Harkess, MD
Memphis, Tennessee Instructor Assistant Professor
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
James H. Calandruccio, MD University of Tennessee–Campbell University of Tennessee–Campbell
Associate Professor Clinic Clinic
Department of Orthopaedic Surgery Memphis, Tennessee Memphis, Tennessee
University of Tennessee–Campbell
Clinic Gregory D. Dabov, MD Robert K. Heck, Jr., MD
Memphis, Tennessee Assistant Professor Assistant Professor
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Francis X. Camillo, MD University of Tennessee–Campbell University of Tennessee–Campbell
Assistant Professor Clinic Clinic
Department of Orthopaedic Surgery Memphis, Tennessee Memphis, Tennessee
University of Tennessee–Campbell
Clinic Jeffrey A. Dlabach, MD Susan N. Ishikawa, MD
Memphis, Tennessee Instructor Assistant Professor
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
S. Terry Canale, MD University of Tennessee–Campbell University of Tennessee–Campbell
Harold B. Boyd Professor and Chairman Clinic Clinic
Department of Orthopaedic Surgery Memphis, Tennessee Memphis, Tennessee
University of Tennessee–Campbell
Clinic Barney L. Freeman III, MD Mark T. Jobe, MD
Memphis, Tennessee Professor Associate Professor
Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Kevin B. Cleveland, MD University of Tennessee–Campbell University of Tennessee-Campbell
Instructor Clinic Clinic
Department of Orthopaedic Surgery Memphis, Tennessee Memphis, Tennessee
University of Tennessee–Campbell
Clinic
Memphis, Tennessee
vii
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viii Contributors
David G. LaVelle, MD Barry B. Phillips, MD A. Paige Whittle, MD
Associate Professor Associate Professor Associate Professor
Department of Orthopaedic Surgery Department of Orthopaedic Surgery Department of Orthopaedic Surgery
University of Tennessee–Campbell University of Tennessee–Campbell University of Tennessee–Campbell
Clinic Clinic Clinic
Memphis, Tennessee Memphis, Tennessee Chief of Orthopaedics, Veterans
Administration Hospital
Santos F. Martinez, MD Robert M. Pickering, MD Memphis, Tennessee
Physical Medicine and Rehabilitation Assistant Professor
Campbell Clinic Department of Orthopaedic Surgery Keith D. Williams, MD
Memphis, Tennessee University of Tennessee–Campbell Assistant Professor
Clinic Director, Spine Fellowship
Marc J. Mihalko, MD Memphis, Tennessee Department of Orthopaedic Surgery
Instructor University of Tennessee–Campbell
Department of Orthopaedic Surgery David R. Richardson, MD Clinic
University of Tennessee–Campbell Instructor Memphis, Tennessee
Clinic Department of Orthopaedic Surgery
Memphis, Tennessee University of Tennessee–Campbell Dexter H. Witte, MD
Clinic Clinical Assistant Professor of Radiology
Robert H. Miller III, MD Memphis, Tennessee Department of Orthopaedic Surgery
Associate Professor University of Tennessee–Campbell
Department of Orthopaedic Surgery E. Greer Richardson, MD Clinic
University of Tennessee–Campbell Professor Memphis, Tennessee
Clinic Co-Director, Foot & Ankle Fellowship
Memphis, Tennessee Department of Orthopaedic Surgery George W. Wood II, MD
University of Tennessee–Campbell Professor
G. Andrew Murphy, MD Clinic Department of Orthopaedic Surgery
Assistant Professor Memphis, Tennessee University of Tennessee–Campbell
Co-Director, Foot & Ankle Fellowship Clinic
Department of Orthopaedic Surgery Jeffrey R. Sawyer, MD Chief of Orthopaedics, Regional
University of Tennessee–Campbell Instructor Medical Center
Clinic Department of Orthopaedic Surgery Memphis, Tennessee
Memphis, Tennessee University of Tennessee–Campbell
Clinic Phillip E. Wright II, MD
Ashley L. Park, MD Memphis, Tennessee Professor
Clinical Assistant Professor Department of Orthopaedic Surgery
Department of Internal Medicine, William C. Warner, Jr., MD University of Tennessee–Campbell
Division of Rehabilitation Medicine Associate Professor Clinic
University of Tennessee College of Department of Orthopaedic Surgery Memphis, Tennessee
Medicine University of Tennessee–Campbell
Memphis, Tennessee Clinic
Memphis, Tennessee
Edward A. Perez, MD
Assistant Professor
Department of Orthopaedic Surgery
University of Tennessee–Campbell
Clinic
Memphis, Tennessee
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Preface
As we begin work on each new edition, we are always greatly expand the ways in which Campbell’s Operative
amazed that the fi eld of orthopaedic surgery continues to Orthopaedics can help physicians ensure the highest quality
produce so many innovative techniques and equipment of care for their patients.
year after year. As with each edition, we have tried to make We are, as always, greatly indebted to our contributors
sure this 11th edition is as comprehensive, up-to-date, and for their hard work in reviewing and revising each chapter.
pertinent to your practice as possible by including tried- This requires large amounts of time out of their profes-
and-true procedures along with the promising newer sional and personal lives, and we are grateful for their
techniques. commitment to making each edition better than the last.
A number of new features have been added in this Our thanks also to the Campbell Foundation personnel—
edition that we hope will make it more “user-friendly.” Kay Daugherty, Linda Jones, Barry Burns, and Joan
The technique descriptions are highlighted with color for Crowson—for amassing all the raw material from 35
quick identifi cation and bulleted for easy reading. Hundreds authors and turning it into readable text with illustrative
of color photographs, including intraoperative photographs, art, photographs, and videos. Without their hard work, the
have been added to illustrate diagnostic and treatment prin- hundreds of folders stuffed with paper would never have
ciples, and color has been added to the line art to empha- evolved into this text. Our deepest appreciation goes to
size important structures and techniques. The number of our patient and supportive spouses, Sissie Canale and Terry
video clips has been expanded to include more frequently Beaty, who endured our struggles with the constant dead-
used but technically diffi cult procedures, including total lines with grace and humor.
elbow arthroplasty, mini-incision total knee arthroplasty, Because of their hard work in amassing all the raw
and shoulder arthroscopy. The techniques demonstrated on material from 35 authors and turning it into readable text
the DVD are listed on the end sheets at the front and back with illustrative art, photographs, and videos, we dedicate
of this book for easy access and reference. this edition to the Campbell Foundation Research and
An exciting addition to this edition is its availability as Publication personnel. Without their hard work, the hun-
a multimedia reference source. In addition to the revised dreds of folders stuffed with paper would never have
and up-dated four-volume text, a fully searchable on-line evolved into this text.
edition will provide instant access to regular updates, an
image library for electronic presentations, and links to James H. Beaty, MD
abstracts of references. We believe these resources will S. Terry Canale, MD
ix
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Surgical Techniques
and Approaches
Andrew H. Crenshaw, Jr. Chapter 1
Surgical Techniques.................... 4 Posterior Approach to the Superomedial Both Sacroiliac Joints or Sacrum... 91
Tourniquets ..................................... 4 Region of the Tibia.......................... 33 Spine ............................................... 92
Radiographs in the Operating Fibula .............................................. 35 Sternoclavicular Joint ..................... 92
Room ........................................... 6 Posterolateral Approach.......................... 35 Acromioclavicular Joint .................. 92
Positioning of the Patient ............... 6 Knee............................................... 36 Shoulder .......................................... 92
Local Preparation of the Patient ..... 7 Anteromedial and Anterolateral Anteromedial Approaches....................... 92
Approaches...................................... 36
Wound Irrigating Solutions..................... 9 Anterior Axillary Approach.................... 94
Anterolateral Approach.......................... 39
Draping ............................................ 9 Deltoid-Splitting Approach..................... 95
Posterolateral and Posteromedial
Draping the Edges of the Incision........... 10 Approaches...................................... 40 Transacromial Approach......................... 95
Posterior Approaches............................. 96
Prevention of Human Medial Approaches to the Knee and
Immunodeficiency Virus Supporting Structures........................ 42 Posterior Inverted U Approach................ 99
Transmission ............................... 10 Transverse Approaches to Menisci............ 43 Humerus ....................................... 100
Special Operative Techniques ........ 11 Lateral Approaches to the Knee and Anterolateral Approach........................ 100
Fixation of Tendon to Bone................... 11 Supporting Structures........................ 45 Posterior Approach to the Proximal
Extensile Approaches to the Knee........... 48 Humerus...................................... 102
Fixation of the Osseous Attachment of
Tendon to Bone............................... 13 Posterior Approaches............................. 51 Approaches to the Distal Humeral
Shaft .......................................... 103
Bone Grafting..................................... 14 Femur ............................................. 52
Elbow ........................................... 105
Anterolateral Approach.......................... 52
Posterolateral Approach........................ 105
Surgical Approaches................... 23 Lateral Approach................................. 55
Extensile Posterolateral Approach.......... 108
Toes................................................ 24 Posterolateral Approach.......................... 55
Posterior Approach by Olecranon
Approach to the Interphalangeal Joints...... 24 Posterior Approach............................... 56 Osteotomy.................................... 108
Approaches to the Metatarsophalangeal Medial Approach to the Posterior Surface Extensile Posterior Approach................ 109
Joint of the Great Toe....................... 24 of the Femur in the Popliteal Space..... 58
Lateral Approach............................... 111
ApJporionatcsh otf ot hthe eL Mesesetar taTrosoesp.h.a..l.a.n..g.e.a..l ........ 25 Latoefr athl eA Fpepmrouarc hi nt ot hteh eP Popolsitteeraiol rS Spuacrefa.c.e. .. 58 Lateral J Approach............................. 112
Medial Approach with an Osteotomy
Calcaneus ........................................ 25 Lateral Approach to the Proximal Shaft of the Medial Epicondyle................. 112
and the Trochanteric Region............... 58
Medial Approach................................. 25 Medial and Lateral Approach............... 113
Lateral Approach................................. 25 Hip ................................................. 60 “Global” Approach............................ 114
Anterior Approaches............................. 60
U Approach........................................ 25 Radius.......................................... 115
Anterolateral Approach.......................... 63
Kocher Approach (Curved L).................. 27 Posterolateral Approach to the Radial
Lateral Approaches............................... 63
Tarsus and Ankle ........................... 27 Head and Neck............................. 115
Posterolateral Approach.......................... 69
Anterolateral Approach.......................... 27 Approach to the Proximal and Middle
Posterior Approaches............................. 73 Thirds of the Posterior Surface.......... 117
Anterior Approach................................ 28
Medial Approach................................. 74 Anterior Approach to the Proximal
Kocher Lateral Approach to the Tarsus
and Ankle...................................... 29 Acetabulum and Pelvis ................... 75 Shaft and Elbow Joint..................... 117
Ollier Approach to the Tarsus................ 29 Anterior Approaches............................. 75 Anterior Approach to the Distal Half
Posterolateral Approach to the Ankle........ 30 Posterior Approach............................... 79 of the Radius................................ 117
Extensile Acetabular Approaches............. 81 Ulna .............................................. 117
Anterolateral Approach to the Lateral
Dome of the Talus........................... 30 Extended Iliofemoral Approach .............. 81 Approaches to the Proximal Third of
the Ulna and the Proximal Fourth
Posterior Approach to the Ankle.............. 31 Ilium ............................................... 89 of the Radius................................ 117
Medial Approaches to the Ankle............. 32 Ischium ........................................... 90 Wrist ............................................. 122
Tibia ............................................... 32 Symphysis Pubis ............................. 90 Dorsal Approaches............................. 122
Anterior Approach................................ 32 Sacroiliac Joint................................ 90 Volar Approach................................. 123
Medial Approach................................. 33 Posterior Approach............................... 90 Lateral Approach............................... 123
Posterolateral Approach.......................... 33 Anterior Approach................................ 91 Medial Approach............................... 124
3
4 Part I • General Principles
SURGICAL TECHNIQUES often is prepared and ready before the tourniquet is infl ated.
Hirota et al., using transesophageal echocardiography
This section describes several surgical techniques especially during arthroscopic knee surgery, showed that asympto-
important in orthopaedics: use of tourniquets, use of radio- matic pulmonary embolism can occur within 1 minute
graphs and image intensifi ers in the operating room, posi- after tourniquet release. They also found that the number
tioning of the patient, local preparation of the patient, and of small emboli depends on the duration of tourniquet
draping of the appropriate part or parts. To avoid repetition infl ation.
in other chapters, operative techniques common to many The exact pressure to which the tourniquet should be
procedures, fixation of tendons or fascia to bone, and bone infl ated has not been determined. Evidence indicates that
grafting also are described. pressures greater than necessary have been used for many
years. The correct pressure depends on the age of the
patient, the blood pressure, and the size of the extremity.
Reid, Camp, and Jacob used pneumatic tourniquet pres-
Tourniquets
sures determined by the pressure required to obliterate the
Operations on the extremities are made easier by the use peripheral pulse (limb occlusion pressure) using a Doppler
of a tourniquet. The tourniquet is a potentially dangerous stethoscope; they added 50 to 75 mm Hg to allow for col-
instrument that must be used with proper knowledge and lateral circulation and blood pressure changes. Tourniquet
care. In some procedures, a tourniquet is a luxury, whereas pressures of 135 to 255 mm Hg for the upper extremity and
in others, such as delicate operations on the hand, it is a 175 to 305 mm Hg for the lower extremity were satisfac-
necessity. A pneumatic tourniquet is safer than an Esmarch tory for maintaining hemostasis. Younger et al. showed,
tourniquet or the Martin sheet rubber bandage. with a prototype automated limb occlusion pressure appa-
A pneumatic tourniquet with a hand pump and an ratus, that tourniquet pressures could be reduced by 43%.
accurate pressure gauge is probably the safest, but a con- This device is now commercially available from Zimmer
stantly regulated pressure tourniquet is satisfactory if it is Patient Care (Dover, Ohio).
properly maintained and checked. A tourniquet should be According to Crenshaw et al., wide tourniquet cuffs are
applied by an experienced individual and not delegated to more effective at lower infl ation pressures than are narrow
someone who does not understand its use. ones. Pedowitz et al. showed that curved tourniquets on
Several sizes of pneumatic tourniquets are available for conical extremities require signifi cantly lower arterial
the upper and lower extremities. The upper arm or the occlusion pressures than straight (rectangular) tourniquets
thigh is wrapped with several thicknesses of smoothly (Fig. 1-1). The use of straight tourniquets on conical thighs
applied cotton cast padding. Krackow described a maneu- should be avoided, especially in extremely muscular or
ver that improves positioning of the tourniquet in obese obese individuals.
patients. An assistant manually grasps the flesh of the Any solution applied to skin must not be allowed to run
extremity just distal to the level of tourniquet application beneath the tourniquet, or a chemical burn may result. A
and firmly pulls this loose tissue distally before the cast circumferential adhesive-backed plastic drape applied to the
padding is placed. Traction on the soft tissue is maintained skin just distal to the tourniquet prevents solutions from
while the padding and tourniquet are applied and the latter running under the tourniquet. Sterile pneumatic tourni-
is secured. The assistant’s grasp is released, resulting in a quets are available for operations around the elbow and
greater proportion of the subcutaneous tissue remaining knee. The limb may be prepared and draped before the
distal to the tourniquet. This bulky tissue tends to support tourniquet is applied. Rarely, a superficial slough of the
the tourniquet and push it into an even more proximal skin may occur at the upper margin of the tourniquet in
position. All air is expressed from the sphygmomanometer the region of the gluteal fold. This slough usually occurs
or pneumatic tourniquet before application. When a sphyg- in obese individuals and is probably related to the use of a
momanometer cuff is used, it should be wrapped with a straight, instead of a curved, tourniquet.
gauze bandage to prevent its slipping during infl ation. The Pneumatic tourniquets should be kept in good repair,
extremity is elevated for 2 minutes, or the blood is expressed and all valves and gauges must be checked routinely. The
by a sterile sheet rubber bandage or a cotton elastic bandage. inner tube should be completely enclosed in a casing to
Beginning at the fi ngertips or toes, the extremity is wrapped prevent the tube from ballooning through an opening,
proximally to within 2.5 to 5 cm of the tourniquet. If a allowing the pressure to fall or causing a “blowout.” The
Martin sheet rubber bandage or an elastic bandage is applied cuff also should be inspected carefully. On older tourni-
up to the level of the tourniquet, the latter tends to slip quets, the firm plastic band that keeps the tourniquet from
distally at the time of infl ation. The tourniquet should be rolling must lie superficial to the infl atable cuff to prevent
infl ated quickly to prevent filling of the superficial veins damage to the underlying structures. Damage has been
before the arterial blood flow has been occluded. Every reported when the plastic band was inserted between the
effort is made to decrease tourniquet time; the extremity skin and the infl atable cuff.
Chapter 1 • Surgical Techniques and Approaches 5
vascular supply of the extremity. In an average healthy
adult younger than 50 years of age, we prefer to leave the
tourniquet infl ated for no more than 2 hours. If an opera-
tion on the lower extremity takes longer than 2 hours, it
is better to finish it as rapidly as possible than to defl ate
the tourniquet for 10 minutes and then reinfl ate it. It has
been found that 40 minutes is required for the tissues to
return to normal after prolonged use of a tourniquet.
Consequently, the previous practice of defl ating the tour-
niquet for 10 minutes seems to be inadequate. Post-
tourniquet syndrome, as fi rst recognized by Bunnell, is a
A
common reaction to prolonged ischemia and is character-
ized by edema, pallor, joint stiffness, motor weakness, and
subjective numbness. This complication is thought to be
related to the duration of ischemia and not to the mechani-
cal effect of the tourniquet. Sapega et al. have documented
interstitial edema, increased capillary permeability, micro-
vascular congestion, and decreased muscle contractility
after 2 to 3 hours of ischemia. Post-tourniquet syndrome
interferes with early motion and results in increased nar-
cotic requirements. Spontaneous resolution usually occurs
within 1 week.
Compartment syndrome, rhabdomyolysis, and pulmo-
nary emboli are rare complications of tourniquet use.
B
Vascular complications can occur in patients with severe
Fig. 1-1 A, Straight (rectangular) tourniquets fit optimally arteriosclerosis or prosthetic grafts. A tourniquet should not
on cylindrical limbs. B, Curved tourniquets best fit conical be applied over a prosthetic vascular graft.
limbs. (From Pedowitz RA, Gershuni DH, Botte MJ, et al: The
Pneumatic tourniquets usually are applied to the upper
use of lower tourniquet infl ation pressures in extremity surgery
arm and thigh. In a prospective study, Khuri et al. found
facilitated by curved and wide tourniquets and integrated cuff
that applying a tourniquet to the forearm is safe and effec-
infl ation system, Clin Orthop 287:237, 1993.)
tive for surgery of the hand and wrist. Michelson and Perry
Any aneroid gauge must be calibrated frequently. Newer also concluded after a prospective study that a well-padded
gauges carry instruction cards with them. They are sold proximal calf tourniquet is safe for foot and ankle surgery.
with test gauges so that the gauges on the tourniquets can Table 1-1 outlines general guidelines for the safe use of
be tested for proper calibration. The test gauge also is an pneumatic tourniquets.
aneroid gauge, however, and is subject to error itself. The The Esmarch tourniquet is still in use in some areas and
test gauge must be tested for accuracy by a mercury is the safest and most practical of the elastic tourniquets. It
manometer. The test gauge should be checked once a is never used except in the middle and upper thirds of the
week, and each tourniquet gauge should be tested with a thigh. This tourniquet has a defi nite, although limited, use
test gauge before it is used. If a discrepancy of more than in that it can be applied higher on the thigh than can the
20 mm between the tourniquet and the test gauge is pneumatic tourniquet. The Esmarch tourniquet is applied
present, the equipment should be discarded, and other in layers, one on the top of the other; a narrow band pro-
equipment that does test properly should be used. One duces less tissue damage than does a wide one.
of the greatest dangers in the use of a tourniquet is an im - The Esmarch tourniquet should not be applied until the
properly registering gauge; gauges have been found to be patient is well anesthetized; otherwise, persistent adductor
300 mm off calibration. In many tourniquet injuries, the muscle spasm may cause the tourniquet to be too loose
gauges were later checked and found to be grossly inaccu- after the muscles have relaxed. A hand towel, folded length-
rate, allowing excessive pressure. wise in four layers, is wrapped snugly as high as possible
Tourniquet paralysis can result from (1) excessive pres- around the upper thigh. The tourniquet is applied over the
sure; (2) insufficient pressure, resulting in passive conges- towel as follows. The chain end is held over the lateral
tion of the part, with hemorrhagic infi ltration of the nerve; surface of the thigh with one hand; the other hand is passed
(3) keeping the tourniquet on too long; or (4) application under the thigh and grasps the rubber strap near the chain
without consideration of the local anatomy. There is no and pulls it taut. The strap is allowed to slip between the
rule as to how long a tourniquet may be safely infl ated. thumb and fi ngers as the hand is brought under and around
The time may vary with the age of the patient and the the thigh; properly performed, this slipping produces a
6 Part I • General Principles
the operating room must wear the same clothing and masks
Table 1-1 • Braithwaite and Klenerman’s
as the circulating personnel. These technicians must have
Modifi cation of Bruner’s Ten Rules
a clear understanding of aseptic surgical technique and
Application Apply only to a healthy limb or with draping to avoid contaminating the drapes in the operative
caution to an unhealthy limb field. Portable radiograph units used in the operating room
Size of tourniquet Arm, 10 cm; leg, 15 cm or wider in large should be cleaned regularly and ideally are not used in any
legs other area of the hospital.
Site of application Upper arm; mid/upper thigh ideally When an unsterile radiograph cassette is to be intro-
Padding At least two layers of orthopaedic wool duced into the sterile fi eld, it should be placed inside a
Skin preparation Occlude to prevent soaking of wool. 50– sterile double pillowcase or sterile plastic bag that is folded
100 mm Hg above systolicfor the arm; over so that the exterior remains sterile. The pillowcase or
double systolic for the thigh; or arm plastic bag is covered by a large sterile towel, ensuring at
200–250 mm Hg, leg 250–350 mm Hg least two layers of sterile drapes on the cassette. The opera-
(large cuffs are recommended for larger tive wound should be covered with a sterile towel when
limbs instead of increasing pressure)
anteroposterior view radiographs are made to avoid possible
Time Absolute maximum 3 hr (recovers in
contamination from the machine as it is moved into
5–7 days) generally not to exceed 2 hr
position.
Temperature Avoid heating (e.g., hot lights), cool if
Portable C-arm image intensifier television fluoroscopy
feasible, and keep tissues moist
allows instantaneous evaluation of the position of fracture
Documentation Duration and pressureat least weekly
fragments and internal fixation devices. Many of these
calibration and against mercury manometer or test
machines have the ability to make permanent radiographs.
maintenance gauge; 3-monthly maintenance
When used near the sterile fi eld, the C-arm portion of the
Modified from Kutty S, McElwain JP: Padding under tourniquets in machine must be sterilely draped (Fig. 1-2A and B). As
tourniquet controlled surgery: Bruner’s ten rules revisited, Injury33:75,
with any electronic device, failure of an image intensifier
2002.
can occur. In this event, backup plain radiographs are nec-
essary. Two-plane radiographs can be made, even of the
singing sound from friction. When it completely encircles hip when necessary, using portable equipment (Fig. 1-2C
the thigh, the tourniquet is overlapped layer on layer, with and D). Closed intramedullary nailing or percutaneous
no skin or towel caught between the layers. This is repeated, fracture fixation techniques may need to be abandoned for
keeping constant tension on the strap, until its application an open technique if the image intensifier fails.
is complete. The hook on the end of the strap is caught in All operating room personnel should avoid exposure to
one of the links of the chain. Care must be taken that radiographs. Proper lead-lined aprons should be worn
excessive tension is not built up gradually as the tourniquet beneath sterile operating gowns. Thyroid shields, lead-
is applied. impregnated eyeglasses, and rubber gloves are now avail-
A Martin rubber sheet bandage can be safely used as a able to decrease exposure further.
tourniquet for short procedures on the foot. The leg is
elevated and exsanguinated by wrapping the rubber bandage
Positioning of the Patient
up over the malleoli of the ankle and securing it with a
clamp. The distal portion of the bandage is released to Before entering the operating room, the surgeon and the
expose the operative area. awake, alert patient should agree on the surgical site, and
Special attention should be given when using tourni- the surgeon should mark this clearly to prevent a “wrong-
quets on fi ngers and toes. A rubber ring tourniquet or a site” error. The position of a patient on the operating table
tourniquet made from a glove fi nger that is rolled onto the should be adjusted to afford maximal safety to the patient
digit should not be used because it can be inadvertently left and convenience for the surgeon. A free airway must be
in place under a dressing, resulting in loss of the digit. A maintained at all times, and unnecessary pressure on the
glove fi nger or Penrose drain can be looped around the chest or abdomen should be avoided. This is of particular
proximal portion of the digit, stretched, and secured with importance when the patient is prone; in this position,
a hemostat. This is a much safer method for digital surgery. sandbags are placed beneath the shoulders, and a thin pillow
It is diffi cult to include a hemostat inadvertently in a digital is placed beneath the symphysis pubis and hips to minimize
dressing. pressure on the abdomen and chest. Large, moderately firm
chest rolls extending from the iliac crests to the clavicular
areas may serve the same purpose.
Radiographs in the Operating Room
When the patient is supine, the sacrum must be well
Often it is necessary to obtain radiographs during an ortho- padded, and when lying on the side, the greater trochanter
paedic procedure. Radiography technicians who work in and the fi bular neck should be similarly protected. When
Chapter 1 • Surgical Techniques and Approaches 7
A B
C D
Fig. 1-2 A and B, Portable C-arm image intensifier television fluoroscopy setup for fracture
repair. C-arm rotates 90 degrees to obtain lateral view. C and D, Technique for two-plane
radiographs during hip surgery with a portable machine for anteroposterior and lateral views.
Film cassette for lateral view is positioned over superolateral aspect of hip.
a muscle-relaxant drug is used, the danger of stretching a should be placed over the area where a nerve may be
nerve or a group of nerves is increased. Figure 1-3 shows pressed against the bone (i.e., the radial nerve in the arm,
traction on the brachial plexus from improper positioning the ulnar nerve at the elbow, and the peroneal nerve at the
of the arm. The brachial plexus can be stretched when the neck of the fi bula).
arm is on an arm board, particularly if it is hyperabducted
to make room for the surgeon or an assistant or for admin-
Local Preparation of the Patient
istration of intravenous therapy. The arm should never be
tied above the head in abduction and external rotation Superfi cial oil and skin debris are removed with a thorough
while a body cast is applied because this position may cause 10-minute soap-and-water scrub. We prefer a skin cleanser
a brachial plexus paralysis. Rather, the arm should be sus- containing 7.5% povidone-iodine solution that is diluted
pended in flexion from an overhead frame, and the position approximately 50% with sterile saline solution.
should be changed frequently. Figure 1-4 shows the posi- Hexachlorophene-containing skin cleanser is substituted
tion of the arm on the operating table that may cause when allergy to shellfi sh or iodine is present or suspected.
pressure on the ulnar nerve, particularly if someone on the After scrubbing, the skin is blotted dry with sterile towels.
operating team leans against the arm. The arm must never This scrub can be performed in the patient’s room just
be allowed to hang over the edge of the table. Padding before surgery or in the operating room. If performed