Understanding Surgical Positioning Injuries I: Injury Types

Surgical procedures always involve risk. With approximately 51 million surgical inpatient procedures occurring annually,[1]complications from infections, anesthesia, and many other factors can be at play. Simply the fact that one cannot ask a patient undergoing surgery if they are comfortable can cause serious problems. Namely, this can result in surgical positioning injuries. When patients are not positioned correctly during surgery, the results can lead to both temporary and long-term conditions after the patient has awoken, with legal action potentially following. In order to help you better understand what your client might be up against and how these incidents occur, we will be doing a series of two posts detailing types of surgical positioning injuries, their causes, and how they can be prevented. This purpose of this first post will be to describe some of the main types of surgical positioning injuries that occur.


What are surgical positioning injuries?

A surgical positioning injury is an integumentary, neurological, vascular, or respiratory injury which occurs when patients have not been correctly positioned for or during a surgical procedure.[2]In positioning a patient for surgery, medical professionals should aim to optimize visualization of and access to the surgical site in a way that also protects the skin and joints, and doesn’t physiologically compromise the patient.[3]If a patient is not placed in this manner, their external and internal organs and systems are at risk, since patients under anesthetic cannot communicate pain, pressure, and other types of discomfort.[4]


Some of the main types of surgical positioning injuries

            While a range of injuries can occur when a patient has been placed or moved improperly during surgery, there are a set number of diagnoses that can come from such a situation. While minor skin lesions and temporary pain might not be serious enough to cause real damage, here are some serious injuries to be aware of:

  • Peripheral nerve injuries: Various nerve injuries caused by poorly positioned patients can result in conditions as minor as a handful of days with a numb arm or as serious as morbidity. It is a leading cause of anesthesia-related litigation,[5]and there are three main types to be aware of:
  1. Ulnar injury: The ulnar nerve, running along the ulna bone, gives sensation to the forearm and fourth and fifth fingers. Injuries to the unlar nerve are the most common peripheral nerves to be injured during surgery.[6]When compressed, feeling is completely cut from the area, and this often occurs when there is extreme flexion of the elbow that stretches the nerve.[7]
  2. Brachial plexus injury:The brachial plexus is a network of nerves extending from the spinal cord through the neck and into the armpit, and when improperly positioned, patients can experience numbness and weakness in the upper extremity. Brachial plexus injuries are the second most common peripheral nerve injured due to improper positioning of patients during surgery.[8]
  3. Spinal cord:The least likely but perhaps most severe peripheral nerve injury is to the spinal cord.[9]Injury to the spinal cord can occur from improper placement of a patient’s neck during a surgical procedure.
  • Tissues ischemia:A restriction of blood supply to tissues which causes a shortage of oxygen necessary to keep tissue alive, ischemia can occur when a patient is improperly adjusted while lying flat on their back.[10]
  • Compartment syndrome: Long surgeries in particular are susceptible to compartment syndrome, particularly when the surgery is done in lithotomy position (a patient lying on his or her back with legs apart) or lateral decubitus position (a patient lying on his or her side).[11]Compartment syndrome is when pressure within muscles builds up to dangerous levels, decreasing blood flow and preventing oxygen from reaching nerve and muscle cells.
  • Pulmonary compromise:When surgery is done in the lateral decubitus position, there is a chance of pulmonary problems, due to the movement of abdominal contents and the mediastinum, which improve airway movement and increase blood flow.[12]


There are, of course, many other conditions that can arise from poor choices made while positioning a patient for surgery, including lower extremity injuries in both joints and nerves, and back pain.[13]However, our next post hopes to move beyond the diagnosis and get to the bottom of why these events occur, identify important risk factors, and detail how these problems might be addressed.

[1]“Surgery Statistics,” John Hopkins Medicine, accessed Aug. 7, 2018, https://www.hopkinsmedicine.org/healthlibrary/conditions/surgical_care/surgery_statistics_85,P01412

[2]Lopes, Camila Mendonca de Moraes, Haas, Vanderlei Jose, Dantas, Rosana Aparecida Spadoti, de Oliveira, Cheila Goncalves, and Cristina Maria Galvao, “Assessment scale of risk for surgical positioning injuries,” Revista Latino-Americana De Enfermagen, Aug. 29, 2016, http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692016000100395&lng=en&tlng=en

[3]“AST Standards of Practice for Surgical Positioning,” Association of Surgical Technologies, n.d., accessed Aug. 7, 2018, http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard%20Surgical%20Positioning.pdf


[5]Lalkhen, Abdul Ghaaliq and Kailash Bhatia, “Perioperative peripheral nerve injuries,” Continuing Education in Anaesthesia Critical Care & Pain, 12(1): Feb. 2012, 38-42.


[7]Pillai, Anil Kumar, Ferral, Hector, Desai, Sudhen, Parachuri, Sudheer, Asselmeier, Scott, and Roberto Perez-Gautrin, “Brachial Plexus Injury Related to Patient Positioning,” Journal of Vascular and Interventional Radiology, 2007 (18), 883-834.


[9]Lalkhen and Bhatia, “Perioperative peripheral nerve injuries,”

[10]“Patient Positioning and Injury (Anesthesia Text)”, Open Anesthesia, Accessed Aug. 7, 2018, https://www.openanesthesia.org/patient_positioning_and_injury_anesthesia_text/



[13]“Continuing Education: Avoiding Lower Extremity Positioning Injuries in the OR,” OR Today Magazine, Jan. 1, 2016, Accessed Aug. 8, 2018, http://ortoday.com/continuing-education-avoiding-lower-extremity-positioning-injuries-in-the-or/