The operating room setup for hand surgery is unique among the surgical disciplines. Surgical retractors and other instruments used in general orthopedic surgery are too large and of little use in hand surgery. It is important for the operating room technicians and nurses to have special instrument trays available for hand surgery (Table 1). It is also important for the operating room surgeon to realize that the uniqueness of hand surgery instruments may result in some surgical support staff being unfamiliar with their use. Instrument room personnel must be reminded of the fine caliber of hand surgery instruments, taking special care not to bend or otherwise damage them during processing. The operating surgeons must also exercise care in handling these instruments. Positioning of the patient on the operating room table as well as anesthetic alternatives deserve special consideration in hand surgery.

For the majority of hand surgical procedures, the patient is positioned supine on an operating room table with the operated hand placed on a hand surgery table that is stabilized with two legs. This table is well padded to prevent pressure sores or contusion to the ulnar nerve. The table is constructed of a radiolucent material, such as Plexiglas or wood, to enable radiographic examination of the hand. Once the patient is positioned, the surgeon should ensure that the contralateral elbow and wrist are well padded and positioned free from pressure or irritation. Likewise, padding is placed beneath the knees and heels to prevent pressure injury that might occur during a prolonged procedure. The knees are positioned in a slightly flexed position to prevent injury to the perineal nerve. Because of the rich vascularity of the hand and upper extremity, procedures are typically performed under a tourniquet. A well-padded 18-inch pneumatic
tourniquet is applied to the upper arm for most surgical procedures. Some prefer the use of a forearm or wrist tourniquet for certain procedures. Of particular importance is to ensure that the edges of the tourniquet have been sufficiently padded prior to tourniquet inflation. Skin injury following tourniquet usage is most frequently seen beneath the tourniquet edge. Care is taken to place an impervious barrier just distal to the tourniquet to prevent the seepage of solutions beneath the tourniquet during the preparing and draping of the extremity. The extremity can be scrubbed with a variety of solutions, including a combination of Hibiclens, alcohol, or Betadine. Sustained scrubbing for 7 to 10 minutes is sufficient. At the conclusion of the surgical scrub and prior to draping, some surgeons prefer to paint the exposed limb with Betadine. The arm can be draped using commercially available hand drapes that generously cover the patient while also accommodating the hand table.