The freeing of hands for open reduction and internal fixation.

Dr Lewicky is from the Department of Orthopedic Surgery, Arizona Health Sciences Center, Tucson, Ariz. Reprint requests: Yuri M. Lewicky, MD, Dept of Orthopedic Surgery, Arizona Health Sciences Center, PO Box 245064, Tucson, Az 85724-5064. Operative repair of fractures is most effi ciently achieved when an experienced surgical team is involved. Expertise and familiarity with instrumentation as well as the benefi t of adequate exposure cannot be overstressed. Training programs typically have access to the latest instrumentation and experienced surgical teams, not to mention an overabundance of helpful hands in the surgical suite. For the physician in private practice, the helpful hands of an attending surgeon, chief or junior resident, or medical student are echoes of the past; they are replaced by those of a single surgical technician whose job already involves instrumentation hand-off. Because of this, physician assistants and fi rst assists are becoming more prevalent at a cost of increased physician overhead. Today’s physician must be conscious of not only the patient, but also the economic aspects of the care given. The ultimate goals remain to “fi rst do no harm” while providing the best possible care to the patient, and second to do this in a timely and effi cient manner. Traditionally, the surgical approach to both-bone forearm fractures and isolated olecranon fractures has been performed with the patient in the supine position.1-5 The forearm commonly is approached via two incisions, a volar Henry approach for the radius and a subcutaneous ulnar border approach for the ulna.2,4 The single-incision Boyd exposure for the proximal radius and ulna is not recommended due to a high incidence of synostosis and a resultant loss of forearm rotation.6-8 Whereas access to the radius can be conveniently achieved on a hand table, access to the ulna cannot due to the forearm being fl exed 90 at the elbow with the hand positioned towards the ceiling. Elbow fl exion of this magnitude necessitates an assistant holding the arm for the duration of the surgical approach to the ulna. Olecranon fractures typically have been approached via a posterior midline incision with attention to curving around the prominent subcutaneous olecranon tip to avoid pressure sensitivity.1,3,5 These fractures also necessitate an assistant to maintain the arm in an across-the-chest position with the elbow fl exed 90 . Both of these procedures have the inherent problem of intraoperative arm position maintenance. Proper arm position management can facilitate fracture repair while decreasing operative time and surgeon frustration. This article presents a maneuver to facilitate operative intervention when assistance is limited. The main advantage of this technique is the freeing of the surgical scrub technicians’ hands for handling of retractors and administration of instruments.