Patient Positioning & Limb Isolation

Clinical Objective

Position the surgical patient on the OR table to optimize access, support physiologic stability, and isolate the distal limb or extremity from the main sterile field using stockinette or equivalent techniques. Proper positioning prevents contact between the prepared site and unprepared regions and allows the scrub technician to maintain sterile field integrity throughout the procedure. Errors in positioning require repositioning that may compromise the sterile field or cause patient injury.

Why This Matters

Limb isolation is often treated as a cosmetic step, but its primary function is contamination prevention — separating the contamination-loaded distal extremity (paw, hoof) from the proximal surgical site. Inadequate isolation is a leading cause of intraoperative field contamination in orthopaedic cases.

Critical Control Points

• Confirm final surgical position before draping begins — repositioning after draping contaminates the field

• Apply stockinette aseptically to isolate the distal limb before gowning and draping

• Pad all pressure points and secure the extremity to prevent intraoperative movement

• Ensure the distal limb suspension system (IV stand, tie-out) does not contact the sterile field

• Verify field of view and surgeon ergonomics before the case is locked in

Positioning & Limb Isolation Checklist

Complete all steps before gowning and draping. Confirm with the surgeon that positioning is finalized before proceeding.

Positioning Record

Step-by-Step Protocol

1. 1

   Finalize positioning on the OR table

   • ·Place patient in the required position (dorsal, lateral, sternal) using approved positioning aids
   • ·Confirm surgical site is accessible and surgeon ergonomics are acceptable
   • ·Pad bony prominences and vulnerable nerve paths before securing
2. 2

   Hang and secure the distal limb

   • ·Suspend the affected limb using an IV stand, orthopedic limb holder, or ceiling-mounted support
   • ·Tie-out at the level of the paw or hoof using a clean bandage or stockinette clip — not directly at the surgical site
   • ·Confirm the limb is at appropriate height and tension for the planned procedure
3. 3

   Apply stockinette aseptically

   • ·Open sterile stockinette and have scrub tech apply while maintaining sterility
   • ·Extend stockinette from the most distal point (paw) proximally past the planned incision site
   • ·Secure the proximal end so it does not slip during manipulation
4. 4

   Confirm isolation before draping

   • ·The distal limb suspension system must be non-sterile, handled by the circulator only
   • ·The stockinette-covered limb is then handed off to the scrub tech and incorporated into the sterile drape
   • ·Verify no gap exists between stockinette and the field drape at handoff
5. 5

   Complete final antiseptic application to any exposed skin within the draping plan before gowning

6. 6

   Lock all positioning aids and confirm patient will not shift during procedure before draping begins

Key Pitfalls

• Repositioning after draping is complete, breaking sterile field integrity

• Stockinette applied by an ungloved or non-sterile team member, contaminating its surface

• Insufficient proximal extension of stockinette, leaving a gap at the surgical site boundary

• IV stand or tie-out contacting the sterile drape during limb manipulation

• Padding omitted on bony prominences in long cases, causing positioning-related injury