Definition/Introduction

Appropriate hand, fingers, wrist, and forearm positioning is often required to facilitate proper exposure to the surgical site and anesthesia administration with easy accessibility to the intravenous (IV) site and the American Society of Anesthesiology (ASA) monitors for the anesthesiologist. The most common surgical positioning is supine, Trendelenburg, and lithotomy position. These positions often require arms in abduction less than 90-degree rested on the armrest or tugged in the neutral position. Whereas in the lateral position, the bottom limb is padded at bony prominence and placed in front of the patient, and the top limb is placed on top with padding in between the arms or flexed at shoulder and elbow. Prone position arms are abducted, but abduction should not exceed more than 90 degrees. An axillary roll is often utilized during prone positioning to prevent compression of the brachial plexus and axillary vascular structures.[1][2]

Issues of Concern

Even after new advances in medicine, perioperative peripheral nerve injuries continue to cause patient disability leading to multiple malpractice claims each year. According to the American Society of Anesthesiologist closed claim study, there were 11,000 claims between the years 2005 to 2014. Where 21% of all claims were related to nerve injury.[3][4] Ulnar neuropathy constituted one-third of the injuries, with an incidence of 0.2% to 0.5%. Brachial plexus nerve injury was reported as 23%, and radial nerve injury was infrequently encountered. Carpal tunnel syndrome from medial nerve injury was one of the most common complaints in disability claims, though median nerve injury reported incidence was only 0.1%.[3][5][6]

Clinical Significance

Ulnar nerve injury is one of the most common peripheral nerve injuries, likely due to the superficial nature of the nerve near the medial condyle. Extreme elbow flexion in a prone position or direct nerve compression may be common modes of injury. Common complaints include numbness to the little finger and wrist. Claw hand deformity is also seen with ulnar nerve injury (flexion at the distal phalangeal and interphalangeal joints and hyperextension at the metacarpophalangeal joints).[4] Brachial plexus injury is most commonly seen in the lateral decubitus position with nerve getting compressed/tractioned near the humeral head.[7] Clinically, nerve injury can involve the upper trunk (C5-C6), causing Walter's tip deformity (arm being medially rotated, adducted, and pronated). Involvement of the lower trunk (C8-T1) will result in claw hand deformity and numbness and weakness in the ulnar nerve distribution. Median nerve injury can result in carpal tunnel syndrome along with weakness/paresthesia around the wrist and radial three and a half fingers.[8] Radial nerve injury can result in numbness or wrist drop from improper positioning of the posterior part of the humerus.[8]

Nursing, Allied Health, and Interprofessional Team Interventions

Proper communication between the entire interprofessional healthcare team, including nursing staff, anesthesiologists, and surgeons, is vital in preventing injury during hand positioning. Understanding the nature of the injury and constant surveillance of the patient can minimize the perioperative incidence of nerve injury. 

The ulnar nerve is commonly injured in prolonged surgery. Efforts should be made to minimize the pressure on the ulnar nerve by tucking the patient's arms by their side in a thumbs-up position. If abduction or flexion is needed, it should be less than 90 degrees. In laparoscopic surgeries where steep positioning is needed, patients on the bean bag with shoulder braces have shown significantly less displacement compared to the memory foam pad.[9][Level 2] Therefore, a bean bag and braces should be used in a Trendelenburg position to avoid cephalad shift and downward force on the shoulder. This can contribute to lowering the risk of injury to the upper brachial plexus.[2][1][3]

If head rotation is necessary, such as in carotid endarterectomy, contralateral arm abduction should be avoided due to the risk of injury to the brachial plexus. Arms could be tucked at the patient's side to avoid any excess traction. Overall, proper communication and frequent positioning checks could help reduce the incidence of injuries perioperatively.[6][10]