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Anatomy, Hand Positioning

Editor: Vikas Gupta Updated: 5/1/2023 6:16:12 PM


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

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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]



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Hearon BF, Frantz LM. Ulnar Nerve Anterior Transmuscular Transposition in the Lateral Decubitus Position. The Journal of hand surgery. 2019 Apr:44(4):346.e1-346.e7. doi: 10.1016/j.jhsa.2018.11.009. Epub 2019 Jan 23     [PubMed PMID: 30685140]


Plastaras CT, Chhatre A, Kotcharian AS. Perioperative upper extremity peripheral nerve traction injuries. The Orthopedic clinics of North America. 2014 Jan:45(1):47-53. doi: 10.1016/j.ocl.2013.09.006. Epub 2013 Oct 31     [PubMed PMID: 24267206]


Prielipp RC, Morell RC, Butterworth J. Ulnar nerve injury and perioperative arm positioning. Anesthesiology clinics of North America. 2002 Sep:20(3):589-603     [PubMed PMID: 12298308]


Grant I, Brovman EY, Kang D, Greenberg P, Saba R, Urman RD. A medicolegal analysis of positioning-related perioperative peripheral nerve injuries occurring between 1996 and 2015. Journal of clinical anesthesia. 2019 Dec:58():84-90. doi: 10.1016/j.jclinane.2019.05.013. Epub 2019 May 22     [PubMed PMID: 31128482]


Chui J, Murkin JM, Posner KL, Domino KB. Perioperative Peripheral Nerve Injury After General Anesthesia: A Qualitative Systematic Review. Anesthesia and analgesia. 2018 Jul:127(1):134-143. doi: 10.1213/ANE.0000000000003420. Epub     [PubMed PMID: 29787414]

Level 2 (mid-level) evidence


Stonner MM, Mackinnon SE, Kaskutas V. Predictors of functional outcome after peripheral nerve injury and compression. Journal of hand therapy : official journal of the American Society of Hand Therapists. 2021 Jul-Sep:34(3):369-375. doi: 10.1016/j.jht.2020.03.008. Epub 2020 Apr 23     [PubMed PMID: 32334939]


Swei SC, Liou CC, Liu HH, Hung PC. Acute radial nerve injury associated with an automatic blood pressure monitor. Acta anaesthesiologica Taiwanica : official journal of the Taiwan Society of Anesthesiologists. 2009 Sep:47(3):147-9. doi: 10.1016/S1875-4597(09)60043-6. Epub     [PubMed PMID: 19762307]

Level 3 (low-level) evidence


Farag S, Rosen L, Ascher-Walsh C. Comparison of the Memory Foam Pad Versus the Bean Bag with Shoulder Braces in Preventing Patient Displacement during Gynecologic Laparoscopic Surgery. Journal of minimally invasive gynecology. 2018 Jan:25(1):153-157. doi: 10.1016/j.jmig.2017.09.009. Epub 2017 Sep 15     [PubMed PMID: 28919502]


Jellish WS, Blakeman B, Warf P, Slogoff S. Hands-up positioning during asymmetric sternal retraction for internal mammary artery harvest: a possible method to reduce brachial plexus injury. Anesthesia and analgesia. 1997 Feb:84(2):260-5     [PubMed PMID: 9024012]

Level 1 (high-level) evidence