e129(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus Raymond Y. Hsu, MD, Craig R. Lareau, MD, Jeom Soon Kim, PhD, Sarath Koruprolu, MS, Christopher T. Born, MD, and Jonathan R. Schiller, MD Investigation performed at the Departments of Orthopaedic Surgery and Medical Physics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
Background: Closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus requires operating directly next to the C-arm to hold reduction and perform fixation under direct imaging. This study was designed to compare radiation exposure from two C-arm configurations: with the image intensifier serving as the operating surface, and with a radiolucent hand table serving as the operating surface and the image intensifier positioned above the table. Methods: We used a cadaveric specimen in this study to determine radiation exposure to the operative elbow and to the surgeon at the waist and neck levels during simulated closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus. Radiation exposure measurements were made (1) with the C-arm image intensifier serving as the operating surface, with the emitter positioned above the operative elbow; and (2) with the image intensifier positioned above a hand table, with the emitter below the table. Results: When the image intensifier was used as the operating surface, we noted 16% less scatter radiation at the waist level of the surgeon but 53% more neck-level scatter radiation compared with when the hand table was used as the operating surface and the image intensifier was positioned above the table. In terms of direct radiation exposure to the operative elbow, use of the image intensifier as the operating surface resulted in 21% more radiation exposure than from use of the other configuration. The direct radiation exposure was also more than two orders of magnitude greater than the neck and waist-level scatter radiation exposure. Conclusions: Traditionally, there has been concern over increased radiation exposure when the C-arm image intensifier is used as an operating surface, with the emitter above, compared with when the image intensifier is positioned above the operating surface, with the emitter below. We determined that, although there was a statistically significant difference in radiation exposure between the two configurations, neither was safer than the other at all tested levels. Clinical Relevance: In contrast to traditional teaching regarding radiation exposure, neither C-arm configuration—with the image intensifier serving as the operating surface or with the image intensifier positioned above a radiolucent hand table—was shown to be clearly safer for pediatric supracondylar humeral fracture fixation.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
A
supracondylar humeral fracture is the most common pediatric elbow injury, accounting for 3% of all pediatric fractures1,2, with 17% of those requiring inpatient
management3. The Wilkins modification of the Gartland classification system is commonly used to describe extension-type fractures4. Nondisplaced (Gartland type-I) fractures can be managed
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e129(1-6)
d
http://dx.doi.org/10.2106/JBJS.M.01076
e129(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 15 A U G U S T 6, 2 014 d
d
d
R A D I AT I O N E X P O S U R E A N D C-A R M P O S I T I O N D U R I N G P E D I AT R I C S U P R A C O N D Y L A R H U M E R A L F R A C T U R E F I X AT I O N
TABLE I Scatter Radiation to the Surgeon and Direct Radiation to the Operative Elbow* Radiation Exposure (mR/min) Image Intensifier Above Table
Image Intensifier as Operating Table
P Value
Surgeon neck level
0.32 ± 0.01
0.49 ± 0.05
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
The Effect of C-Arm Position on Radiation Exposure During Fixation of Pediatric Supracondylar Fractures of the Humerus Raymond Y. Hsu, MD, Craig R. Lareau, MD, Jeom Soon Kim, PhD, Sarath Koruprolu, MS, Christopher T. Born, MD, and Jonathan R. Schiller, MD Investigation performed at the Departments of Orthopaedic Surgery and Medical Physics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
Background: Closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus requires operating directly next to the C-arm to hold reduction and perform fixation under direct imaging. This study was designed to compare radiation exposure from two C-arm configurations: with the image intensifier serving as the operating surface, and with a radiolucent hand table serving as the operating surface and the image intensifier positioned above the table. Methods: We used a cadaveric specimen in this study to determine radiation exposure to the operative elbow and to the surgeon at the waist and neck levels during simulated closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus. Radiation exposure measurements were made (1) with the C-arm image intensifier serving as the operating surface, with the emitter positioned above the operative elbow; and (2) with the image intensifier positioned above a hand table, with the emitter below the table. Results: When the image intensifier was used as the operating surface, we noted 16% less scatter radiation at the waist level of the surgeon but 53% more neck-level scatter radiation compared with when the hand table was used as the operating surface and the image intensifier was positioned above the table. In terms of direct radiation exposure to the operative elbow, use of the image intensifier as the operating surface resulted in 21% more radiation exposure than from use of the other configuration. The direct radiation exposure was also more than two orders of magnitude greater than the neck and waist-level scatter radiation exposure. Conclusions: Traditionally, there has been concern over increased radiation exposure when the C-arm image intensifier is used as an operating surface, with the emitter above, compared with when the image intensifier is positioned above the operating surface, with the emitter below. We determined that, although there was a statistically significant difference in radiation exposure between the two configurations, neither was safer than the other at all tested levels. Clinical Relevance: In contrast to traditional teaching regarding radiation exposure, neither C-arm configuration—with the image intensifier serving as the operating surface or with the image intensifier positioned above a radiolucent hand table—was shown to be clearly safer for pediatric supracondylar humeral fracture fixation.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
A
supracondylar humeral fracture is the most common pediatric elbow injury, accounting for 3% of all pediatric fractures1,2, with 17% of those requiring inpatient
management3. The Wilkins modification of the Gartland classification system is commonly used to describe extension-type fractures4. Nondisplaced (Gartland type-I) fractures can be managed
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e129(1-6)
d
http://dx.doi.org/10.2106/JBJS.M.01076
e129(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 15 A U G U S T 6, 2 014 d
d
d
R A D I AT I O N E X P O S U R E A N D C-A R M P O S I T I O N D U R I N G P E D I AT R I C S U P R A C O N D Y L A R H U M E R A L F R A C T U R E F I X AT I O N
TABLE I Scatter Radiation to the Surgeon and Direct Radiation to the Operative Elbow* Radiation Exposure (mR/min) Image Intensifier Above Table
Image Intensifier as Operating Table
P Value
Surgeon neck level
0.32 ± 0.01
0.49 ± 0.05
