O2087: To Shield or Not to Shield? Shielding Pediatric Patients During Bedside Fluoroscopy Reduces Radiation Exposure

Background: Pediatric patients are sensitive to the effects of radiation. There are no established standard protocols or society guidelines supporting the use of radiation shielding for the patient during orthopedic procedures requiring fluoroscopic guidance despite frequent use. Consequently, wide variation remains among institutions. Some position papers have suggested that shields may even increase radiation exposure to the patient due to scatter of the X-ray beams. In this study, we sought to quantify the amount of radiation at 3 critical anatomic locations during a simulated bedside upper extremity fracture reduction with various shielding configurations.

Methods: A mannequin (Laerdal Medical) approximating the size of an average 5-year-old was placed supine on a standard hospital bed with the upper extremity extended over a self-supporting radiolucent hand table (AliMed). Exposures were performed with an imagine intensifier of a standard fluoroscopy machine (GE Healthcare) placed below the arm and repeated with the intensifier above the arm, all at 110 kVp and 4.5 mA for 10 seconds. Radiation exposure was assessed with a dosimeter (Mirion Technologies) in 3 locations: thyroid, breast, and groin. Readings were assessed without a standard rectangular radiation shield first, then assessed in four shielding variations: Anterior Only, Posterior Only, Anterior+Posterior, and Anterior+Side. Each configuration was replicated 5 times.

Results: Without shielding, the thyroid received 110 mSv/132.7 mSv (intensifier below/above), the breast received 125.8 mSv/118.8 mSv, and the groin received 44.9 mSv/46.7 mSv. With the intensifier below and the radiation projected from above, radiation was significantly (p < 0.01) reduced at all locations with Anterior, Anterior+Side, and Anterior+Posterior shielding. With the intensifier above and the radiation projected from below, radiation was significantly reduced (p < 0.01) with Anterior, Anterior+Side, and Anterior+Posterior shielding in all locations except for Anterior shielding at the groin. Where fold decrease calculations were possible, Anterior shielding decreased exposure by about 2-fold. Anterior+Side shielding decreased exposure to undetectable levels at the groin. There was no significant reduction with Posterior shielding at any location or intensifier configuration, with radiation significantly increasing (p < 0.01) at the groin.

Conclusion: Shields placed Anterior, Anterior+Posterior, or Anterior+Side significantly reduce radiation exposure in the thyroid, breast and groin regions by at least 2-fold. The use of a Posterior shield confers no additional protection. This study offers the first of its kind data supporting the use of Anterior+Side radiation shielding during upper extremity procedures irrespective of whether the radiation source is above or below the patient, dispelling any assumptions that shielding can lead to harmful scatter or increased exposure. Providers should strongly consider placing anterior and possibly side shields on the patient when performing a bedside procedure requiring fluoroscopy.