title: Direct beam radiation exposure to surgeons during pinning of supracondylar humerus fractures: does C-arm position and the attending surgeon matter?
abstract: BACKGROUND
  Direct beam radiation exposure to the surgeon, especially to their hands, is extremely common during supracondylar humerus fracture pinnings and results in exposure to significantly greater doses of ionizing radiation when compared with scatter radiation. The purpose of this study was to determine how often surgeons are exposed to direct beam radiation during this surgery and whether the C-arm position and the surgeon's experience influence radiation exposure.
  
  
  METHODS
  In this double blind study, we collected 3842 fluoroscopic still images from 78 closed reduction and percutaneous pinning surgeries for supracondylar humerus fractures performed or supervised by 6 attending surgeons. The percentage of images containing a surgeon's body was calculated as an indicator of direct beam radiation exposure. Total fluoroscopy time, C-arm position (standard or inverted), and whether the primary surgeon was an attending, resident, or both were recorded. Nonparametric statistical analyses were performed.
  
  
  RESULTS
  Fluoroscopy lasted for a median of 34 seconds, and the surgeon was exposed to direct beam radiation in a median of 13% of fluoroscopy films, with exposure ranging from 0% to 97% per surgery. Fluoroscopy was significantly longer when the C-arm position was inverted when compared with the standard position (43 vs. 26 s, P=0.034). Surgeons' exposure to direct beam radiation was also slightly greater when the C-arm position was inverted (16% vs. 10%, P=0.087). The duration of fluoroscopy exposure and the percentage of films with the body exposed to radiation did not differ based on whether the surgery was performed by an attending, a resident, or both (P=0.53 and 0.28, respectively). However, the percentage of films with bodily radiation exposure did significantly differ between the attending physicians (P=0.029).
  
  
  CONCLUSIONS
  Direct beam radiation exposure varied widely between surgeries and surgeons, ranging from none to nearly constant exposure. Surgical time also significantly increased with the C-arm in the inverted position compared with the standard position. Given the significant variation in exposure between attending physicians, it is likely that exposure to direct beam radiation can be avoided with improved awareness about the risk of direct beam radiation exposure and cautious surgical technique.
  
  
  METHODS
  Not applicable.
authors.affiliation: *Division of Orthopaedic Surgery †Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Eismann
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Wall
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: Thomas
authors.forename: Megan A
authors.initials: MA
authors.lastname: Little
mesh_terms: D004311:Double-Blind Method; D005260:Female; D005471:Fluoroscopy / Q000379:methods*; D005592:Fracture Fixation / Q000379:methods*; D006801:Humans; D006810:Humeral Fractures / Q000000981:diagnostic imaging* / Q000601:surgery; D007396:Internship and Residency; D008505:Medical Staff, Hospital; D016273:Occupational Exposure; D009985:Orthopedics; D011829:Radiation Dosage; D011839:Radiation, Ionizing; D013997:Time Factors