Radiation Protection Dosimetry (2020), pp. 1–6 doi:10.

1093/rpd/ncaa026

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EVALUATION OF THE RADIATION DOSE TO THE HANDS OF
ORTHOPAEDIC SURGEONS DURING FLUOROSCOPY USING
STORED IMAGES
Carlo Giordano1, *, Ivo Monica2 , Fabrizio Quattrini2 , Elena Villaggi1 , Rossana Gobbi1
and Lorenzo Barbattini3
1
Medical Physics Department, AUSL Piacenza, via Taverna 49, 29121 Piacenza, Italy
2
Orthopaedics and Traumatology Department, AUSL Piacenza, via Taverna 49, 29121 Piacenza, Italy
3
Radiology Department, AUSL Piacenza, via Taverna 49, 29121 Piacenza, Italy

*Corresponding author: c.giordano@ausl.pc.it

Received 20 September 2019; revised 16 December 2019; editorial decision 12 February 2020; accepted 12
February 2020

Data were collected from 642 orthopaedic interventions during which the images produced by X-rays were recorded. By examining
these images, it is possible to determine the time that the orthopaedic surgeons’ hands were exposed to the direct radiation beam.
The procedures with greater exposure to the direct beam were those involving the hand (median 15 s) and the wrist (median
13 s). Two surgeons wore a ring to measure the absorbed dose at the fingers: one on the dominant hand and the other on the
non-dominant hand. The two surgeons performed 34 and 48 operations, respectively, in 14 months. The total doses measured
with the rings were 2.30 and 1.04 mSv, respectively. The images of the interventions were examined, determining how much each
individual hand was exposed. The interventional reference point (IRPeff (left or right) ) was calculated by comparing the doses at
the IRP with the exposure times of the right or the left hand. Summing the IRPeff of the two surgeons in 14 months, it is obtained
the maximum values of 2.87 mGy for the left hand of one and 6.74 mGy for the right hand of the other, which are of the order
of 1/100 of the annual dose limit for the extremities.

INTRODUCTION In most cases, radiation exposure to the hands of

orthopaedic surgeons derives from scattered radia-
X-ray units have been used extensively in orthopaedic
tion but there are situations in which there is also a
operating theaters since the 1980s(1) . The image
contribution from primary radiation. According to
intensifiers of that period were not able to memorize
Arnstein et al.(13) , the dose within the primary beam is
the last image acquired, which led to an increase in
100 times higher than the scattered radiation at 15 cm
the times of X-ray delivery and consequently of the
and according to Mahajan et al.(14) , the scattered
exposure of the operators to radiation. Technological
dose at 46 cm is 0.1% of the dose from the direct beam.
developments subsequently led to the introduction of
International Commission of Radiological Protection
various improvements that have reduced the exposure
117(1) states that ‘exposure of staff may be unavoid-
of both patients and theater staff to radiation, such
able when maintaining a difficult reduction, confirm-
as the storage of images and greater filtering of the
ing adequate bony alignment or securing implant
radiation beams as well as marketing of specifically
placement’, even if in these cases ‘there is evidence of
designed equipment (mini C-arms).
poor radiological protection practices.’
The exposure of orthopaedic surgeons to radiation
The purposes of this study were to assess the
is heterogeneous, because they must normally wear
level to which the hands of orthopaedic surgeons are
lead gowns and therefore the parts exposed, in
exposed in our center and in particular if and how
particular the hands, are substantially those not
important the contribution of direct beam to the total
covered by the protective clothing. Many studies
absorbed dose is.
that have evaluated the exposure of staff involved in
orthopaedic procedures have been published in the lit-
erature. In particular, the review by Kesavachandran
et al.(2) presents data from various authors(3–11) who
MATERIALS AND METHODS
reported annual doses at the extremities far below the
dose limit (500 mSv). However, Tsalafoutas et al.(12) Data from 642 operations carried out between
believe that there is a lack of reliable data as many December 2017 and April 2019 were collected and
theater staff do not wear a dosemeter regularly. analyzed. The mobile C-arm system used in these

© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com
 C. GIORDANO ET AL.
orthopaedic procedures was a Philips BV Pulsera 9R2
equipped with an image intensifier with a diameter of
23 cm, with the tube positioned below the operating
table. The interventional reference point (IRP) was
at a distance of 30 cm from the intensifier in the
direction of the tube: this position approximately
represents where the beam enters the patient and
also, occasionally, the surgeon’s hands. During each
intervention, the fluoroscopy images were stored,
at an average rate of two images per second, and,
at the end of each procedure, were sent to the
picture archiving and communication system (PACS)
together with the radiation dose structured report
(RDSR): the latter reports the kerma-area product
(KAP), the air kerma at the IRP and the time of
fluoroscopy. For each patient, all the recorded images
(N im ) were visually examined, counting the number
in which the surgeon’s hands appeared (N hand ), which
in this case intercepted the direct beam of radiation.
When counting the N hand images no distinction was
made between hands intercepted by the beam totally,
partially or individually. Given that the number of
images (N im ) is proportional to the total time of
fluoroscopy (T fluoro ), the time during which the
hands were exposed to the direct beam (T hand ) was
determined as follows: T hand = (N hand /N im ) × T fluoro .
The operations were divided according to the
anatomical district involved, but the type of interven-
tion performed was not taken into account. Images
that included different districts and that could not be
unequivocally categorized were grouped in a separate
category called ‘miscellaneous.’ The anatomical
districts identified were: hand, wrist, forearm, elbow,
humerus, shoulder, foot, ankle, tibia-fibula, knee
and femur. The interventions were performed by
13 surgeons, who were assigned, as normal, cuff
dosemeters to measure the radiation received by the
extremities, and a dosemeter to be attached to the
lead gown to evaluate the effective dose. Two of the 13
surgeons made themselves available for more accurate
measurements using an additional ring dosemeter.
The dosemeters, whose reading is supplied in Hp
(0.07), were produced by the Tecnorad company of
Verona (Italy), and were replaced every 2 months.
The types of dosemeter used were TLD LiF:
MCP GR-200A or MCP-N. The observation period
was 14 months and therefore there were seven
dosimetric results available per surgeon, although
the same surgeons did not always work during these
periods. Surgeon A wore the ring dosemeter on
the little finger of the non-dominant hand, while
surgeon B wore it on the ring finger of the dominant
hand. Both surgeons had >15 years of experience,
neither is left handed. At the end of each 2-month
period, the surgeons involved returned forms with
a description of each intervention carried out and
subsequently they viewed the images recorded on
the PACS distinguishing if and which hand appeared
2
on the monitor in every image. Thus, the exposure
times to the direct beam of the dominant and
non-dominant hand of each doctor have been
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derived (T hand (left or right) ). Finally, a parameter IRP
effective (left or right) = IRP dose × T hand (left or right) /T fluoro
was also determined, which indicates the dose at the
IRP given during the exposure of each extremity to
the direct beam.
RESULTS
The data relating to the range, the median and the
75th percentile of the fluoroscopy times, the dose to
the IRP and the KAP are shown in Table 1. The IRP
dose and the KAP were corrected for the calibration
factors, which, for the C-arm used, were 1 for the IRP
dose and 1.07 for the KAP. In 75% of the cases the
fluoroscopy time was <74 s, with the exception of the
‘miscellaneous’ procedures, which were generally in
patients with multiple trauma.
The medians of the data related to the wrist, tibia,
hand, ankle, humerus, shoulder and femur are in
line with those reported by Giordano et al.(15) with
differences being generally <30%.The data relating
to the evaluation of the contribution of the direct
beam to the radiation dose to the hands are shown
in Table 2. It can be seen that the anatomical districts
that required longer operating times were the extrem-
ities of the upper limbs (hand and wrist). Among
the 17 ‘miscellaneous’ procedures, those in which the
exposure times to the direct beam were greater than
the median (8 in total) included four involving the
upper limbs. The others were operations for multiple
trauma to the lower limbs. It can be seen that, despite
the relatively long fluoroscopy times (median 38 s)
(Table 1), the operator’s hands were barely exposed
to the direct beam during operations involving the
femur. An intermediate situation was noted for oper-
ations to the humerus during which the fluoroscopy
times were longer overall (median 53 s), and the
extremities were exposed to radiation for a median of
7 s.
In the period between March 2018 and April 2019,
surgeons A and B performed 46 and 58 procedures,
respectively. In some interventions, the two surgeons
were listed as ‘assistant surgeon’ and not as ‘first sur-
geon’; since it is the hands of the first surgeon that are
typically exposed to the direct radiation beam, only
the cases in which the two surgeons were recorded
as ‘first surgeon’ were considered. The total number
of interventions therefore fell to 34 for surgeon A
and 48 for surgeon B. The districts on which surgeon
A operated were the ankle (n = 1), femur (n = 23),
hand (n = 1), humerus (n = 2), wrist (n = 3), tibia
(n = 2), knee (n = 1) and miscellaneous (n = 1); those
of surgeon B were the ankle (n = 2), femur (n = 16),
elbow (n = 2), hand (n = 5), humerus (n = 2), tibia
 EVALUATION OF THE RADIATION DOSE TO THE HANDS OF ORTHOPAEDIC SURGEONS
Table 1. Summary of fluoroscopy time, dose (mGy) at the IRP and KAP data.

N Time (s) Dose at IRP (mGy) KAP (μGy m2 )

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Range Median 75th Range Median 75th Range Median 75th

FEMUR 218 1–194 38 54 0.01–27.3 3.40 5.6 0.14–508.2 63.7 106.9

KNEE 33 2–90 10 27 0.04–4.2 0.30 1.1 0.71–76.1 5.5 14.0
TIBIA 77 0–195 42 74 0.01–7.7 0.68 1.4 0.11–134.8 14.7 30.3
ANKLE 50 3–142 25 33 0.02–2.2 0.37 0.57 0.33–40.6 6.3 10.7
FOOT 50 1–102 5 13 0.003–1.3 0.05 0.15 0.06–24.4 0.90 2.4
SHOULDER 24 1–73 11 31 0.06–3.2 0.54 1.2 1.66–60.5 10.1 21.8
HUMERUS 51 3–139 53 74 0.03–4.9 1.38 2.0 0.47–101.2 25.8 41.1
ELBOW 27 4–202 19 40 0.05–4.5 0.25 0.62 0.85–82.8 4.5 11.5
FOREARM 13 1–100 10 18 0.01–2.0 0.11 0.19 0.19–14.9 2.1 4.0
WRIST 44 1–106 28 41 0.01–1.4 0.26 0.47 0.06–32.0 4.7 7.7
HAND 38 1–223 21 44 0.01–1.6 0.16 0.35 0.10–30.0 2.4 5.4
MISCELLANEOUS 17 29–222 76 144 0.49–18.7 1.91 9.2 9.13–348.8 35.6 170.1

Table 2. Summary of the exposure times of the hands to the direct beam according to the type of procedure.

N Hands under the direct beam (s)

Range Median 75th

FEMUR 218 0–49 0 1

KNEE 33 0–15 1 4
TIBIA 77 0–132 5 14
ANKLE 50 0–43 4 11
FOOT 50 0–50 3 7
SHOULDER 24 0–25 0 4
HUMERUS 51 0–73 7 14
ELBOW 27 0–154 5 8
FOREARM 13 0–39 1 4
WRIST 44 0–76 13 20
HAND 38 0–207 15 25
MISCELLANEOUS 17 1–49 14 25

(n = 7), wrist (n = 5), radius-ulna (n = 3), knee (n = 1),
shoulder (n = 1) and miscellaneous (n = 4).
The dosimetric results and some of the two sur-
geons’ operating data are shown in Tables 3 and 4.
The dose read by the dosemeter placed on the chest
on the outside of the leaded gown was zero in all
cases (nominal value attributed to dosimetric read-
ings lower than 0.02 mSv).
The nominal reading of the ring dosimeter of the
period January–February 2019 of physician B was
zero. However, it was considered more reasonable
to assign the minimum declared sensitivity value
(0.02 mSv) since the dosimeter was nevertheless
exposed, albeit for a short time. In the same Tables 3
and 4, the value of extended uncertainty percentage
is provided by the Tecnorad company.
Subsequently, the relationship between the dose
measured by the ring dosemeter and the exposure
parameters reported in the RDSR was studied.
The correlation between the measured dose and
the time of exposure of the hands to the direct beam
is strong (R2 = 0.40) for the doctor A and very strong
(R2 = 0.81) for the doctor B, while it is very good
that between the dose measured with the ring and
the IRPeffective left or right parameter (R2 equal to 0.97 for
doctor A and 0.81 for doctor B [see Figures 1 and 2]).
Examining Tables 3 and 4, if the sum of the col-
umn of ‘IRPeff (left or right) ’ is added, the dose delivered
to the IRP is obtained during exposure of the hands
to the direct beam throughout the period considered.
The maximum total values are 2.87 mGy for doctor
A’s left hand and 6.74 mGy for doctor B’s right hand.
DISCUSSION
The RDSR data of the operations recovered from the
PACS are in line with those collected in a study of

3
 C. GIORDANO ET AL.

Table 3. Exposure data of the surgeon A.

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Surgeon A

N Dosimetric Extended Screening time Time with left Time with right IRPeff left IRPeff right
reading (mSv) uncertainty (s) hand under hand under (mGy) (mGy
percentage beam (s) beam (s)

2018
March–April 4 0.09 60 159 8 10 0.05 0.08
May–June 10 1.57 45 470 41 6 2.02 0.29
July–August 0 0 - 0 0 0 0 0
September–October 8 0.28 50 238 17 3 0.27 0.04
November–December 0 0 - 0 0 0 0 0
2019
January–February 7 0.20 55 278 1 8 0.11 0.56
March-April 5 0.16 55 237 11 14 0.42 0.53
Total 34 2.30 1382 78 41 2.87 1.50

Table 4. Exposure data of the surgeon B.

Surgeon B

N Dosimetric Extended Screening time Time with left Time with right IRPeff left IRPeff right
reading (mSv) uncertainty (s) hand under hand under (mGy) (mGy
percentage beam (s) beam (s)

2018
March–April 10 0.15 55 399 58 48 1.15 0.82
May–June 7 0.16 55 427 32 54 0.83 1.60
July–August 8 0.20 55 474 71 67 1.14 1.24
September–October 8 0.33 50 569 250 174 2.13 2.03
November–December 11 0.18 55 393 26 20 0.93 0.96
2019
January–February 4 <0.02 70 211 6 2 0.34 0.09
March–April 0 0 0 0 0 0 0 0
Total 48 1.04 2473 443 365 6.52 6.74

Figure 1. Dosimetric reading surgeon A vs IRPeff left .

4
 EVALUATION OF THE RADIATION DOSE TO THE HANDS OF ORTHOPAEDIC SURGEONS
Figure 2. Dosimetric reading surgeon B vs IRPeff right .
patients’ exposure to radiation performed in 2014–
2015 in the same center(15) . The operations that
involve exposure to higher radiation doses to the
hands of the orthopaedic surgeon are essentially
those to the hand and the wrist, while exposure to the
direct beam is almost negligible in the case of femoral
surgery, regardless of whether the operation involved
intramedullary nailing, a cannulated hip screw or
less invasive stabilization system plates. Tables 3 and
4 show, first of all, that the exposure times for the
hands are greater for the non-dominant hand, even
for the doctor A almost double the other. The doses
to the IRP are higher during the exposure of the
non-dominant hand for the doctor A, while for the
doctor B there is a slight prevalence for the dose
dispensed to the right hand. The dosages detected by
the dosemeter are always low except for a reading,
they are always <0.5 mSv. However, the measured
data are quite different between the two surgeons and
this may be due to several factors.
First of all the ring dosemeters were worn at
different places: on the little finger of the non-
dominant hand of surgeon A and on the ring
finger of the dominant hand of surgeon B. The
choice of using different positions for the ring
dosemeter derives from the fact that the literature
is not clear on which is the most exposed hand in
the case of orthopaedic procedures. According to
Vosbikan et al.(16) , the non-dominant hand appeared
to be more exposed during operations to the hands
and wrists, whereas Mahajan et al.(14) found no
differences. Hafez et al.(4) reported that the radiation
dose absorbed was higher for the dominant hand,
but only for trainee surgeons: there were no practical
differences for experienced surgeons. According
to Martin and Whitby(17) , ring dosemeters should
be worn on the little fingers of both hands in
order to monitor the radiation dose correctly at
the upper limb extremities during interventional
radiology.
5
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A second reason is that the exposure of the hand
to the direct beam in the orthopaedic field occurs
in an irregular and usually partial way. Therefore,
a precise measurement could be performed only by
assigning more dosemeters to each surgeon’s hand, a
procedure that is impossible to achieve systematically
for obvious practical reasons.
In certain types of interventions (hand, wrist), the
surgeon’s hand is exposed entirely for relatively long
times to the direct beam without the patient’s attenu-
ation, for others (femur, tibia) the exposure is limited
to the phalanges and often the beam is attenuated by
the patient, so that despite the presence of relatively
high IRPeff values, it is possible that the extremities of
the surgeon have instead absorbed little dose as they
are placed on the side of the patient opposite the tube.
Therefore, it can be deduced that, at the end of the
14 months of observation, the doses absorbed by the
two surgeons, were surely not higher than previous
recorded data of ‘IRP eff (left or right) ’ converted into
mSv. The conversion between mGy and mSv can be
performed since in the range of energies used (average
30–50 keV) the conversion coefficient between air
kerma and Hp (0.07) is only slightly higher than
one(18) . The doses absorbed by the surgeons in our
center are comparable to those found in other studies
published in the literature. Kesavachandran et al.(2)
reviewed a collection of publications with annual
dosimetric data. The measured doses ranged from
0.03 to 1.27 mSv(3–11) . In an analysis of 80 lower
limb operations, Singh et al.(19) evaluated that the
surgeon’s right hand was exposed to a radiation dose
of 2.4 mSv, while Khan et al.(20) considered that the
absorbed dose to the fingers during femoral surgery
was 0.13 mSv per procedure.
CONCLUSIONS
The hands of an orthopaedic surgeon are exposed
in different ways to the direct beam of radiation
 C. GIORDANO ET AL.
during the various interventions performed. This
direct beam is the major source of irradiation, since it
is some orders of magnitude greater than the contri-
bution from scattered radiation. The time of exposure
to direct beam irradiation can be estimated in our
center from stored images. In the two cases analyzed,
a correlation was found between dose absorbed by
the hands and exposure time to the direct beam. In
the light of the results from our center, as well as data
published in the literature, it can be concluded that the
dose absorbed by the hands of orthopaedic surgeons
rarely exceeds one-tenth of the maximum annual dose
limit (500 mSv); in our case, in which the exposure of
two doctors is examined, it can be concluded that in
14 months a doctor certainly did not exceed 3 mSv
and the other 7 mSv. Furthermore, it can be assumed
that it may be precautionary to wear the dosimeter at
the ends of the non-dominant hand, as it is exposed
to the direct beam for longer times.
REFERENCES
1. International Commission of Radiological Protection.
Radiological protection in fluoroscopically guided proce-
dures performed outside the imaging department. Ann.
ICRP 40(6), 50–60 (2010) ICRP Publication 117.
2. Kesavachandran, C. N., Haamann, F. and Nienhaus, A.
Radiation exposure of eyes, thyroid gland and hands in
orthopaedic staff: a systematic review. Eur. J. Med. Res.
17, 28 (2012).
3. Müller, L. P., Suffner, J., Wenda, K., Mohr, W. and
Rommens, P. M. Radiation exposure to the hands and
the thyroid of the surgeon during intramedullary nailing.
Injury 29(6), 461–468 (1998).
4. Hafez, M. A., Smith, R. M., Matthews, S. J., Kalap, G.
and Sherman, K. P. Radiation exposure to the hands of
orthopaedic surgeons: are we underestimating the risk?
Arch. Orthop. Trauma Surg. 125, 330–335 (2005).
5. Miller, M. E., Davis, M. L., MacClean, C. R., Davis,
J. G., Smith, B. L. and Humphries, J. R. Radiation
exposure and associated risks to operating-room per-
sonnel during use of fluoroscopic guidance for selected
orthopaedic surgical procedures. J. Bone Joint Surg. Am.
65, 1–4 (1983).
6. Sanders, R., Koval, K. J., Di Pasquale, T., Schmelling,
G., Stenzler, S. and Ross, E. Exposure of the orthopaedic
surgeon to radiation. J. Bone Joint Surg. Am. 75(3),
326–330 (1993).
7. Levin, P. E., Schoen, R. W. Jr. and Browner, B. D.
Radiation exposure to the surgeon during closed inter-
locking intramedullary nailing. J. Bone Joint Surg. Am.
69, 761–766 (1987).
8. Rampersaud, Y. R., Foley, K. T., Shen, A. C.,
Williams, S. and Solomito, M. Radiation exposure to
the spine surgeon during fluoroscopically assisted pedicle
Downloaded from https://academic.oup.com/rpd/article-abstract/doi/10.1093/rpd/ncaa026/5823517 by James Cook University user on 23 April 2020
screw insertion. Spine (Phila Pa 1976) 25, 2637–2645
(2000).
9. Faulkner, K. and Harrison, R. M. Estimation of effec-
tive dose equivalent to staff in diagnostic radiology. Phys.
Med. Biol. 3, 383–391 (1988).
10. Muzaffar, T. S., Imran, Y., Iskandar, M. A. and
Zakaria, A. Radiation exposure to the surgeon during
femoral interlocking nailing under fluoroscopic imaging.
Med. J. Malaysia 60(Suppl C), 26–29 (2005).
11. Biswas, D., Bible, J. E., Bohan, M., Simpson, A. K.,
Whang, P. G. and Grauer, J. N. Radiation exposure
from musculoskeletal computerized tomographic scans. J.
Bone Joint Surg. Am. 91, 1882–1889 (2009).
12. Tsalafoutas, I. A., Tsapaki, V., Kaliakmanis, A.,
Pneumaticos, S., Tsoronis, F., Koulentianos, E. D.
and Papacristou, G. Estimation of radiation doses
to patients and surgeons from various fluoroscopically
guided orthopaedic surgeries. Radiat. Prot. Dosimetry
128, 112–119 (2008).
13. Arnstein, P. M., Richards, A. M. and Putney, R. The
risk from radiation exposure during operative X-ray
screening in hand surgery. J. Hand Surg. Br. 19, 393–396
(1994).
14. Mahajan, A., Samuel, S., Saran, A. K., Mahajan, R. K.
and Mam, M. K. Occupational radiation exposure from
C arm fluoroscopy during common orthopaedic surgical
procedures and its prevention. J. Clin. Diagn. Res. 9(3),
RC01–RC04 (2015).
15. Giordano, C., Monica, I., Gobbi, R. and Barbattini,
L. Determination of local levels of radiation exposure
in orthopaedic interventions using structured dose report
data drawn from the hospital picture archiving and com-
munication system. Radiat. Prot. Dosimetry 178(19),
82–86 (2018).
16. Vosbikan, M. M., Ilyas, A. M., Watson, D. D. and
Leinberry, C. F. Radiation exposure to hand surgeons’
hands: a practical comparison of large and mini C-
arm fluoroscopy. J. Hand Surg. Am. 39, 1805–1809
(2014).
17. Martin, C. J. and Whitby, M. Application of ALARP to
extremity doses for hospital workers. J. Radiol. Prot. 23,
405–421 (2003).
18. ENEA. Dosimetria personale esterna in termini di
equivalente di dose personale, Hp (d). (Atti giornata di
studio) 28 February 2001.
19. Singh, P. J., Perera, N. S. and Dega, R. Measurement of
the dose of radiation to the surgeon during surgery to the
foot and ankle. J. Bone Joint Surg. Br. 89-B, 1060–1063
(2007).
20. Khan, I. A., Kamalasekaran, S. and Fazal, M. A. Risk
of ionising radiation to trainee orthopaedic surgeons.
Acta Orthop. Belg. 78, 106–110 (2012).