Executive Editor: James Hunter General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric proximal forearm

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Lateral decubitus position



  • Good position for access to the posterior aspect of the elbow
  • 110° elbow flexion is possible
  • Reduced risk of contamination of the hanging hand
  • Straightforward for anesthesia


  • Use of the C-arm is more difficult
  • Less suitable for children below 6-8 years due to short upper arm

Preoperative preparation

The following are essential for successful surgery:

  • Patient information
  • Operating room personnel (ORP) information/instruction
  • Surgical planning

Information for operating room personnel

Operating room personnel (ORP) need to know and confirm:

  • Consent form, completed and signed
  • Site and side of fracture
  • Type of operation planned
  • Surgical approach
  • Operative site has been marked by the surgeon
  • Condition of soft tissues
  • Equipment/implants needed
  • Patient positioning
  • Duration of operation
  • Positioning of image intensifier
  • Antibiotic prophylaxis
  • Comorbidities, including allergies

Surgical planning

The surgeon should make sure that:

  • Relevant x-rays and other images are available in the OR.
  • Required instruments and implants are accessible and ready.
  • Tourniquet is available (a sterile tourniquet makes draping more straightforward).
  • Image intensification is available.
  • Intraoperative x-ray documentation should be undertaken, with clear AP and lateral views, before applying any plaster cast.
  • There is a clear, step-by-step plan of the operation, including backup plans.


  • General anesthesia
  • Local nerve block
  • Combination of nerve block and light general anesthesia
  • Prophylactic antibiotics (see local microbiological protocols.)

Lateral position enlarge

Patient positioning

Place the patient in a lateral decubitus position on the uninjured side, as close as possible to the edge of the table, with trunk support front and back.

The contralateral shoulder must be carefully positioned to prevent brachial plexus injury.

Place the injured arm either on a gutter support beneath the upper arm, or over a padded arm roll under the elbow.

Lateral position - C-arm positioning enlarge

C-arm positioning

Position the C-arm parallel to the operating table.

For AP view extend the elbow.

Lateral position - C-arm positioning enlarge

For lateral view rotate the C-arm, not the forearm.

Lateral position - Skin disinfecting and draping enlarge

Skin disinfecting and draping

With an assistant holding the arm, disinfect the entire arm down to the fingertips.

Drape the hand in a glove or leave it free.

Drape the arm up to the shoulder.

Lateral position - OR set-up enlarge

OR set-up

The optimal position of the surgeon is perpendicular to the operating table in front of the elbow.

The position of the screen should allow a direct view for the surgeon.

The position of operating room personnel should permit ergonomic assistance.

v1.0 2019-08-28