Abstract 2

A Novel Approach to Reducing Radiation Exposure in Operative Fixation of Proximal Phalanx Fractures

Joseph Weinstein, DO, Farhan Karim, DO, Adam Bitterman, DO, Craig Roberto, DO

No financial support was provided for this manuscript.  The authors deny any conflicts of interest associated with this manuscript.

Abstract
Radiation exposure to the human body can have serious consequences, of which, the most serious includes malignancy.  In a trauma setting, orthopaedic surgeons are often working with x-ray imaging for the reduction and fixation of fractures, resulting in high cumulative exposure to radiation.  Additionally, reduction of radiation exposure to patients is of paramount concern.  Techniques designed to reduce radiation exposure can lead to greater health safety for the surgeon as well as the patient.  We present a novel technique designed to reduce radiation exposure to the operative hand as well as the surgeon’s hand through the use of common items available in the operating room.  This technique not only reduces harm, but also provides greater visualization to the surgeon and assists with the reduction and fixation of fracture fragments in the finger.

Figure 1

Set up for minimal radiation exposure.

 

Figure 2

Set up for minimal radiation exposure.

Figure 3

AP image with the use of this technique

Figure 4

Lateral image with the use of this technique

Introduction
Since Wilhelm’s Rontgen’s initial publication of radiographs of his wife’s hands, radiation has taken a unique place in assisting clinicians to define bony intricacies.  With the early descriptions of hand and wrist anatomy by Bryce came multiple reports of radiation dermatitis of the hand.1,2 Several reports of “x-ray finger” were published describing edema, bullae, stiffness, erythema and tenderness.2  These early doses of radiation were not quantified, eventually resulting in the first radiation associated legal cases.  What followed were several reports of radiation related carcinomas resulting in several upper extremity amputations.3 It was clearly evident that radiation was impacting physicians as well.  The Mayo Clinic profiled 135 cases of physician radiodermatitis with 93% affecting the practitioner’s hands.3

Radiation exposure is of primary concern to the Orthopaedic surgeon, especially for cases involving the use of fluoroscopy.  Despite several advances in technology to reduce the amount of radiation emitted, lifetime local exposure is still of paramount concern to the surgeon.  With regards to hand surgery advances such as use of mini c-arm fluoroscopy decreases whole body radiation.4

Radiation exposure is classified into two types, Whole body irradiation, which usually involves a large portion of the body involving at least 1/3 of the bone marrow resulting in bone marrow suppression.  Local Irradiation refers to exposure restricted to exposed tissues.  The mechanism of radiation injury is when ions and free radicals are generated resulting in DNA damage due to membrane permeability which radiation destroys.5  The amount of biological damage from a certain dose of radiation is measured in Sieverts.  When a surgeon’s hands are overexposed certain tissues are left more prone to exposure than others. The order of sensitivity to radiation is as follows: bone marrow, skin, endothelium, fat, bone, muscle and nerve.6  The earliest sign of local injury is erythema and edema in the first week, however, it is followed generally by stiffness, “pin pricking sensation,” and tenderness.7  Progressive damage includes epithelial and subcutaneous fat atrophy, skin sensitivity, loss of pigmentation and skin appendages.  For Hand Surgeons, especially important is the dorsum of the hand, which is more severely affected.  Chronic low doses will eventually result in eczematoid skin changes or ulceration.8

In 2005 a report by Mastrangelo in Occupational Medicine entitled, “Increased cancer risk among surgeons in an orthopaedic hospital,” was released detailing the increased cancer risk for orthopedic surgeons.9  Long-term fluoroscopic exposure is considered to be a form of chronic low dose radiation exposure. Mini C Arm use is recommended because it results in 2-10 times less radiation exposure.10  Despite the low dose claims of Mini C Arm use, local exposure is considerable.  According to a study by Singer, the radiation scatter rate decreases precipitously outside the beam or beyond the radius of the intensifier.10  An average exposure to the hands of 20 mrem/case suggests that surgeons’ hands must be entering the beam and getting direct radiation exposure.  A dose of 20 mrems is equivalent to a standard chest x-ray.  

However, in a study by Tuohy using Ring Dorsomiters for radiation exposure, it was discovered that the average the radiation exposure was 6.3 mrem/case.4  As radiation exposure is cumulative over a lifetime studies generally vary in terms of annual caseload it takes to reach radiation limits.10 Singer’s study quantifies it as 2500 cases based on their estimation of mrem/case.  However, a study by Thomson and La-Londe concluded that 12,000 cases could be done annually without exceeding the annual exposure limit.11 A great level of variability exists in the literature and that is attributed to whether the surgeon’s hands enter the field of radiation, which is multifactorial based on the surgeon’s experience, assistance, type of case, as well as the type of image intensifier used.

Techniques designed to reduce the surgeon’s exposure to radiation include increased protection such as lead gloves.  However, these have proved to be disadvantageous, cumbersome and may obscure proper exposure when attempting to capture an image.

With regards to specific cases, trauma cases are those that require the most intraoperative fluoroscopy.  Hand and upper extremity trauma cases can involve complex reductions, which often require extensive positioning and imaging.  Specifically, when managing phalangeal fractures, positioning the injured finger for optimal x-ray views has been known to be tedious.  At this time, there exists no device to our knowledge to position the non-operative fingers away from the radiation beam.  Often a battle with positioning, it becomes very difficult for the surgeon to position a single digit while obtaining an image and holding the reduction.  These difficult situations often result in more images being taken resulting in unnecessary exposure to the patient’s non-operative digits as well as the practitioner.

Axial traction has traditionally been the method used for reduction of phalangeal fractures.12 We present and describe a novel technique to protect both the surgeon’s and patient’s hands, and reduce overall local radiation exposure.  In addition, we feel that this technique may aid in fracture reduction.

Materials and Methods
Sterile technique is maintained throughout the procedure.  Surgeons and operating room technicians are expected to use whole body radiation protective equipment throughout the procedure. For reduction of P1 or P2 fractures the technique of axial traction is utilized.  In addition to standard surgical tools required for cases, CobanTM (3M Inc.) is utilized along with standard sterile surgical finger traps.  The use of a mini c-arm is utilized for all cases where a reduction is involved.

 The patient is placed supine on an operating room table with the standard hand table attachment. Finger traps are placed on the non-operative fingers; they should be a snug fit. Another finger trap is placed distal to the operative site and secured proximally with CobanTM.  CobanTM is again used and two to three passes are secured about four to six inches proximal to the wrist.  The non-operative fingers are maximally flexed starting from the ulnar digits.  They are secured by wrapping each finger trap chain within another pass of the CobanTM.  All of the finger traps are then reinforced with another two to three passes of CobanTM.  The operative digits within finger trap can be further secured with some reinforcing CobanTM, tape, or Steri StripsTM.

At this point while securing the wrist and pulling slight traction on the operative finger the surgeon is able to manipulate the x-ray view while keeping his hands out of the x-ray field.  An x-ray can be obtained that is free from obstruction due to the other non-operative digits.  A clear A/P and lateral fluoroscopy image may be obtained by rotating the wrist and the finger trap on the operative finger.  If traction is needed for fracture reduction a greater force may be used while placing traction on the finger. (Figure 1,2)

Conclusion
Radiation exposure is of great concern to orthopedic surgeons.  However, these considerations are especially important for hand surgeons whose hands are constantly exposed to radiation. As shown in figures 3, and 4, fluoroscopy with this technique is extremely clear.  Our technique is one designed to reduce radiation exposure to all parties as well as obtain a more anatomic reduction.

References

  1. Bryce T. Certain points in the anatomy and mechanism of the wrist-joint reviewed in the light of a series of Röntgen ray photographs of the living hand. J Anat Physiol 1896;31:59–79.
  2. Hansen F, Edgerton M. Burns and frostbites: radiation burns. In: Flynn J, ed. Hand surgery. 3rd ed. Philadelphia: Williams and Wilkins, 1982:577–586.
  3. Porter C, White C. Multiple carcinoma following chronic x-ray dermatitis. Ann Surg 1907;46:649.
  4. Tuohy CJ, Weikert DR, Watson JT, Lee DH. Hand and body radiation exposure with the use of mini C-arm fluoroscopy. J Hand Surg Am. 2011;36(4):632-8.
  5. Chambers JA, Long JN. Radiation injury and the hand surgeon. J Hand Surg Am. 2008;33(4):601-11.
  6. Hansen F, Edgerton M. Burns and frostbites: radiation burns. In: Flynn J, ed. Hand surgery. 3rd ed. Philadelphia: Williams and Wilkins, 1982:577–586.
  7. Goans E, Toohey R, Hart M. Section 21—Techniques of decontamination. Medical planning and care in radiation accidents course. Oak Ridge, TN: Oak Ridge Institute for Science and Education and Radiation Emergency Assistance Center/Training Site, 2001.
  8. Berger M, Hurtado R, Dunlap J, Mutchinick O, Velasco M, Tostado R, et al. Accidental radiation injury to the hand: anatomical and physiological considerations. Health Phys1997;72:343–348.
  9. Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med 2005;55:498 –500.
  10. Singer G, Herron B, Herron D. Exposure from the large C-arm versus the mini C-arm using hand/wrist and elbow phantoms. J Hand Surg Am. 2011;36(4):628-31.
  11. Thomson CJ, LaLonde DH. Measurement of radiation exposure over a one-year period from Fluoroscanmini C-arm imaging unit. Plast Recon Surg 2007;119:1147–1148.
  12. Bucholz RW, Heckman JD. Rockwood and Green’s fractures in adults. Lippincott Williams & Wilkins; 2009.

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