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Radiation hazards in orthopaedic trauma care

Learning outcomes
Describe the physical and biological facts of radiation. Demonstrate an understanding of how and when to use x-rays during orthopaedic trauma procedures. Protect patients, teams and surgeons from radiation during surgery.

Outline
Physical facts Biological facts How to protect team and surgeon C-arm and x-ray tube position Protective clothing Efficient use of radiation Planning Positioning "C-arm attitude"

Physical facts
Radiation is energy from electromagnetic waves X-radiation = ionizing radiation Wavelength: 150.01 nanometer (nm) Frequency: 2.5x10176x1019 Hz Energy: 1 eV250 keV

Units of measurement Rem: energy delivered by x-radiation Gray (1 Gy = 1 Joule/kg): energy deposited in material, reflects physical effect Sievert (1 Sv = 1 Joule/kg): dose equivalent, reflects the biological effect

Physical facts
Units 100 rem = 1 Gy = 1 Sv 100 milirem = 1 mGy = 1 mSv (=1000 Sv) Normal exposure Cosmic ray in high-altitude flights: 0.0010.01 mSv/hour Natural background radiation: 0.01 mSv/day In USA: natural cosmic radiation is 0.27 mSv/year

Physical facts

Medical exposure Chest x-ray: CT scan head: CT whole body: Cardiac CT angio:

0.1 mSv 1.5 mSv 9.9 mSv 6.713 mSv

Physical facts

Accidental exposure Radiation sickness: 5001000 mSv Radiation from nuclear bomb: 5001000 mSv

Biological factsionizing radiation


Somatic effectsdetermined by dose Early effect: radiation sickness from 5001000 mSv Late effect: leukemia, thyroid cancer, radiation cataract Below certain threshold, no increased risk of radiation-induced problems Stochastic effectsnot determined by dose (chance) Cumulative damage, no threshold Late effect, eg, thyroid cancer, leukemia

Biological factsionizing radiation


Genetic effects Mutagenic effects related to dose proved in animals Teratogenic effects At 1885 days of gestation provoked by 10 mSv

Biological facts
85% of papillary carcinomas = radiation induced

Carcinogenic dose of radiation to induce thyroid carcinoma = 100 mSv


Threshold value per year: Thyroid 300 mSv Eye 150 mSv Hand 500 mSv

Modern orthopaedic trauma surgery


Increased exposure of surgeon, patient, and team to radiation by minimally invasive procedures Intramedullary (IM) nailing Percutaneous K-wire fixation

Vertebroplasty
MIPO

Exposure during MIO procedures


Fuchs M et al (1998) Intl Orthopedics

K-wire distal radius

Intramedullary nail

External fixator lumbar spine

Average radiation dose Sv (1/1000 mSv)

Eye Thyroid Hand Gonads

1.1 Sv 1.1 Sv

19.0 Sv 35.4 Sv

49.8 Sv 55.5 Sv

3.1 Sv

41.7 Sv

117.0 Sv

Safety regulation limits radiation exposure on professionals to 300500 mSv/y

How to protect staff and surgeon


Physical facts X-ray tube position Factors affecting patient and staff doses

Protection measures

Physical facts
Absorption and scatter: For every 1000 photons reaching the patient ~100200 are scattered ~ 20 reach the image detector rest are absorbed (= radiation dose) by the patient In radiology, radiation scatter is mainly directed toward the source

The main source of radiation for the team and surgeon during fluroscopy is scattered radiation from the patient

X-ray tube position

Scatter-dose rate is lower when distance between patient and surgeon increases

Example of dose rate around mobile C-arm

Stand at safe distance from image intensifier and x-ray tube!

Further away from patient, lower rate of scattered radiation

Who receives the most exposure?


Tasbas BA et al (2003) Arch Orthop Trauma Surg 3-month period: 107 consecutive operations

Radiation doses of surgeon and assistant


Surgeon always > 90 cm from beam Assistant approx 10 cm from beam Outer dosimeter: Surgeon Assistant 0.0375 mSv 0.21 mSv

Under-gown dosimeter:

Surgeon
Assistant

0.0 mSv
0.05 mSv

Experience and exposure during IM nailing


Blattert TR et al (2004) Arch Orthop Trauma Surg

22 procedures of IM nailing of long bones Senior group (12) vs junior group (10)

Dosimetry data and fluorometric time


Fluorometric time statistically greater for junior group

X-ray tube position

X-ray tube position


x-ray tube down

intensifier up

Tube position below OR table reduces high-dose rates to eye lens


Radiation dose reduced to lens by 3 or more times Best configuration
intensifier up

x-ray tube down

X-ray tube position


Scattered dose is higher at the xray tube side Stand on intensifier side

Staff should stay clear of the x-ray tube area during fluoroscopy

X-ray tube position


Rampersaud YR et al (2000) Spine Risks: Thyroid exposure Source side (x-ray tube) 34 times higher than on intensifier side Dose rates to torso 0.53 mSv/min on source side 0.02 mSv/min on intensifier side

Factors affecting staff and patient doses


Patient size increases skin dose and scattered radiation

Patient skin dose and level of scattered radiation increases substantially

Use additional protective devices or keep a safe distance from large size patients

Factors affecting patient doses


Intensifier diameter
Relative patient entrance dose

32 cm (12 in)

Dose 100

22 cm (9 in) 16 cm (6 in) 11 cm (4.5 in)

Dose 150
Dose 200

Dose 300

A smaller image intensifier diameter can increase patient entrance dose

Factors affecting staff and patient doses


Important parameters: Focuspatient skin distance Patientimage intensifier distance Patient dose will increase if: Focusskin distance is short Patientimage intensifier distance is large

Reduce scatter: place patient close to image intensifier and far from x-ray tube

dose

Specific body exposure


Hands have greatest exposure risk Eyes: first determinant of workload
(radiation cataract)

Thyroid: 85% of papillary carcinoma are radiation induced


Carcinogenic dose of radiation to induce thyroid carcinoma = 100 mSv
[Devalla KL, Guha A, Devadoss VG 2004]

Image on the right courtesy of Fuezesi I, Gastroenteropathology UMG, Goettingen

Practical radiation protection


0.15 mm lead-equivalent goggles provide 70% attenuation of radiographic beam Thyroid collar 2.5-fold further decreases Apron AP: decreased 16-fold lateral: decreased 4-fold

6064% protection at 5258 KV

Practical radiation protection


Shielding, leaded aprons, gloves, thyroid protectors, etc, must be available in the OR! They must always be properly used!

Technical contributions to radiation dose reduction


Integrated lasers on both x-ray tube and image intensifier, easier positioning, reduce radiation exposure Pulse acquisition Virtual patient anatomy selection ensure correct dose is given to corresponding body area Selectable dose rate according to patient size

reduced dose reduced dose standard dose increased dose

Clinical C-arm application: C-arm attitude


Landmarks (floor, body)

Laser
Pulsed acquisition Distance Position of x-ray tube Protection

Clinical C-arm applicationDHS

Summary
Radiation hazard can be reduced by: C-arm orientation Positioning x-ray tube underneath the patient Lateral view: stay away from x-ray tube Keep x-ray tube at maximal distance to the patient Keep image intensifier close to the patient Do not overuse magnification Considering scatter radiation Wearing protective clothing Keeping distance Keeping your hands out of the beam!

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