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 with no pressure on the elbow. This position can be achieved with the use of pillows, a sling, or a stockinette device.

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 with heels 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, involved humerus fracture repairs, 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.

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.

Surgery technique and surgeon preference will determine the appropriate position of postoperative hip patients. For the patient with a posterior or lateral total hip replacement, proper body alignment can be achieved with placement of an abduction pillow between the knees. 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, which is a minimally invasive procedure, does not normally require dislocation precautions. Therefore, there is usually no need for an abduction pillow, traction sling, or hip cushion to assist with positioning.² See Box 37.1 for various surgical approaches.

The perianesthesia nurse should also be familiar with various types of orthopedic equipment that may be used that can affect positioning. At times, 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. However, evidence is showing that the inconvenience and expense may not outweigh the benefit of CPM.³ See further discussion in the section Perianesthesia Care After Knee Surgery.

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 rest 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.

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, decreased sensation, and swelling (Box 37.2). Pain is common with patients for orthopedic surgery, and the approach to treatment must be individualized. Pain unrelieved with conventional methods, such as elevation, repositioning, and the administration of opioids, must be assessed further. Color indicates circulatory compromise.⁴ 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.

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, enabling 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 PACU, the cast may still be wet, and, if so, special care must be taken to prevent indentations (such as using 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.⁴ 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.

A patient with total joint replacement may commonly have a large amount of blood loss in the immediate postoperative period. The total perioperative blood loss in hip arthroplasty is typically over 200 mL.⁵ Blood loss can be significant with all major orthopedic surgeries, but with advances in technology and the implementation of minimally invasive techniques, attempts are being made to keep blood loss at a minimum. Autotransfusion may be used in the form of cell saver in the operating room (OR). Autotransfusion is accomplished with the use of self-contained disposable systems designed for easy setup and safe use. The retrieval of this blood for reinfusion (autotransfusion), in addition to new medical management, has substantially reduced the need for homologous or autologous transfusions. Additionally, an antifibrinolytic agent, such as tranexamic acid, is one emerging medication used to reduce blood loss in orthopedic surgeries.⁵ Regardless of blood-conserving techniques used, if the patient experiences excessive amounts of blood loss in the PACU, surgeon notification is recommended.