Full text of DOI:10.1016/S0020-1383(99)00310-1

Injury, Int. J. Care Injured 31 (2000) 351±352
www.elsevier.com/locate/injury
Image intensi®er position for hand and wrist fractures
G. Van Staden, K. Farrant, R. Richards, T. Bunker
Princess Elizabeth Orthopaedic Centre and Royal Devon & Exeter Hospital, Exeter, UK
Accepted 10 November 1999
1. Introduction
ing that it is the radiation scatter back from the oper-
ating room ¯oor which endangers the surgeon, and
not the direct beam. This can make the job of the sur-
geon well nigh impossible. We therefore decided to
examine the relative radiation to the surgeon while
using the C-arm in the regulation manner and in the
inverted position.
The Ionising Radiations Regulations (1995) [1] dic-
tate that when radiographers use C-arm image intensi-
®cation the radiation source should be placed below
the patient and the collimator above the patient. Such
a position works well for common procedures such as
pinning hip fractures and performing intramedullary
®xation of long bones. However, when reducing and
pinning small fractures, such as those of the hand,
wrist and foot, better de®nition is required by the sur-
geon, and this means getting the collimator as close to
the fracture as possible. If the radiation source is
below the fracture, and the collimator above, then as
the collimator is approximated to the wrist fracture,
the surgeon's view of what he is doing is impeded.
Moreover with the collimator lowered down on to the
fracture the source is closer to the ¯oor and therefore
the cone of radiation comes closer to the surgeon, who
is unable to stand away from the source because he is
maintaining the reduction. Psychologically it is daunt-
ing for the surgeon to be looking at the radiation
source, whether he is close to, but outside the cone of
radiation, or whether he is within it. For these reasons
it has been common practise for surgeons to invert the
C-arm for such procedures. This allows the collimator
to be placed immediately adjacent to the fractured
part (albeit with a radiolucent hand table between the
two to prevent damage to the collimator), gaining bet-
ter de®nition of the fracture. Most importantly it
allows the surgeon to see what he is doing, both physi-
cally and on the image intensi®er at the same time.
Finally it allows the surgeon to be well outside the
cone of radiation, both physically and psychologically.
However, radiographers now refuse to grant the
request of surgeons to invert the C-arm for hand and
wrist fractures, quoting the 1995 regulations, and stat-
2. Method
A typical operating room scenario was created in a
Nuclear Medicine measurement laboratory portraying
a forearm manipulation. A phantom arm, made of
perspex blocks and a stainless steel rod was used to
simulate the forearm, based on kilovoltage (kV) data
collection from actual theatre measurements used for
similar procedures, found to lie between 50±55 kV.
The phantom forearm was placed on a radiolucent
support table 70 cm from the ¯oor. The ¯oor surface
was identical to that found in the operating suite, and
would therefore have the same re¯ective qualities. A
``phantom surgeon'' was now placed 40 cm distant to
the phantom forearm, and a 180 cm3 ionisation
chamber dosimeter was used to measure the amount
of radiation exposure at various body sites of the
phantom surgeon. A dosimeter was placed at 10 cm
from the ¯oor to represent the ankle and foot; at 80 cm
behind a 0.25 mm lead apron to represent the groin; at
152 cm to represent the thyroid and at 170 cm to rep-
resent the eyes; ®nally dosimeters were placed at either
end of the phantom forearm (outside the cone of pri-
mary radiation) to represent the hands of the operat-
ing surgeon. A Picker Orbiter C-arm Image Intensi®er
was used for screening at 52 kV with the source below
the phantom forearm (as required by the 1985 Ionising
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PII: S0020-1383(99)00310-1

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G.N. Van Staden et al. / Injury, Int. J. Care Injured 31 (2000) 351±352
fracture care becomes more and more complex, and
both patients and their legal advocates expect ever
improving standards, screening times in orthopaedic
and trauma operating theatres are set to continue to
rise. It therefore behoves every member of the operat-
ing theatre team to be increasingly aware of radiation
protection measures. Whilst the inverse square law,
and lead gowns, can protect radiographers, nurses,
and anaesthetists, the surgeon is often unable to stand
back from the radiation source during the screening,
for he is either having to manually hold a fracture re-
duction, or hold an internal ®xation device (drill or
screw). Ionising Radiation Regulations have therefore
been enforced in order to protect the patient and the
most vulnerable member of the operating team, the
surgeon.
In the area of reduction and ®xation of hand and
wrist fractures, and to a certain degree foot fractures,
the regulations come into con¯ict with the surgeons
ability to see what he is doing. As far as we could
determine this con¯ict of interests has not previously
been researched. We therefore decided to investigate
whether obeying the regulations was in the best inter-
ests of radiation protection to the surgeon during such
manoeuvres, or not. The results in fact show that the
regulation method not only prevents the surgeon from
seeing what he is doing, but also causes increased radi-
ation to the surgeon's eyes and thyroid. Conversely, by
inverting the image intensi®er such that the collimator
is below the forearm and the source above, not only
allows the surgeon to see what he is doing but also
gives less radiation to his eyes and thyroid.
Fig. 1. Illustrating the positions used to simulate theatre forearm
procedure and the resultant radiation dosages measured.
Radiation Regulations), and then with the C-arm
inverted (the surgeon preferred method.)
Screening times of a number of seconds were needed
to allow a dose to be read by the dosimeter, which
was measured in milliGrays per hour (mGy/h.)
As a control, similar screenings were performed on
an anatomical body phantom simulating screening of a
hip fracture, using 81 kV from an average of clinically
collected dosage of kV data.
3. Results
Radiation dosages for the phantom forearm using
the intensi®er with the source below the patient and
inverted are shown in Fig. 1. With the radiation source
below the patient (regulation) higher doses were
obtained for the eyes and thyroid than with the source
above the phantom (surgeon preferred), but the dosage
to the hands was less. Both methods showed equal
dosage to the foot and ankle, and no radiation was
measured at the leaded groin.
We would therefore conclude that the Ionising Radi-
ation Regulations should be amended to allow sur-
geons operating on the periphery of the limbs to invert
the image intensi®er so that the source is above the
patient and the collimator below, should they deem it
necessary for reduction or ®xation of hand, wrist or
foot fractures.
Measurements on the hip phantom showed that the
regulation method of source below the patient was
safer to the surgeon.
References
4. Discussion
[1] Royal Devon & Exeter Healthcare Trust Rules for Use of
Ionising Radiation, Version 1.1, September 1995, Appendix 3,
Section 9iii.
The image intensi®er is an indispensable tool in the
area of fracture reduction and fracture ®xation. As