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American Association for Hand Surgery

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Investigating Patient-Level Radiation Exposure in Hand and Wrist Surgery
Wen Xu, MD, Adrienne Christopher, MD, Sophia Hu, BS, Natalie Beckmann, PhD and Ines C. Lin, MD, University of Pennsylvania, Philadelphia, PA

Background
While occupational exposure to radiation has been previously studied in the hand surgery literature, there is a paucity of studies looking at radiation exposure to the patient during fluoroscopy-guided hand surgery. We aim to describe the level of radiation experienced by patients undergoing common hand and wrist fracture fixation and to identify risk factors for increased radiation exposure.
Methods
We performed a retrospective review of patients at a single institution who underwent fracture fixation of the hand, wrist, or forearm requiring fluoroscopic guidance with the mini c-arm from 2016-2020. Datapoints collected included patient demographics, procedural details, and indicators of radiation exposure including dose-area product (DAP), total intraoperative images, and total fluoroscopy time. Effective dose (ED) was calculated using DAP, field size, and a previously-established conversion factor. Statistical analysis included descriptive statistics, and 2-sample t tests with statistical significance set at p < 0.05.
Results
The final sample included 361 patients. Average patient age was 46 years with the majority being female (56.5%). Procedures included fixation of forearm fractures (3.3%), distal radius fractures (35.7%), metacarpal fractures (30.8%), and phalangeal fractures (30.2%). The average number of intraoperative images acquired was 45 images [95% CI = 41-48]. Average total fluoroscopic time was 55.7 seconds [95% CI = 50.9-60.5], average DAP was 6.1017 cGycm2 [95% CI = 5.5153-6.6881], and average effective dose was 0.17 µSv [95% CI = 0.15-0.18]. Distal (metacarpal and phalangeal) fractures required more intra-operative images and longer total fluoroscopy time (49 images, 61.3 seconds) compared to proximal (forearm and distal radius) fractures (39 images, 46.9 seconds) (images: p = 0.0011, exposure time: p = 0.0009). However, distal fractures had a lower average ED compared to proximal fractures (0.15 µSv vs. 0.19 µSv, p=0.0138). When compared to open procedures like open reduction internal fixation, closed procedures had higher DAPs (8.8359 vs 4.9191 cGycm2, p < 0.0001), higher ED (0.22 vs 0.15 µSv, p=0.0007), more intraoperative images (65 vs 36 images, p < 0.0001), and longer total fluoroscopy time (81.9 vs 44.4 seconds, p < 0.0001).
Conclusion
Patient radiation exposure during fluoroscopy-guided hand and wrist procedures is low in comparison to other medical imaging like dental radiographs (ED ~5µSv) and chest xrays (ED ~100µSv). Fixation of more distal fractures requires more intra-operative images and longer fluoroscopy time but results in lower ED. Closed treatment of fractures is associated with more intra-operative images, longer fluoroscopy time, and higher DAP and ED values.


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