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Injury. 2015 Dec;46(12):2457-60. doi: 10.1016/j.injury.2015.10.010. Epub 2015 Oct 16.

Defining reference levels for intra-operative radiation exposure in orthopaedic trauma: A retrospective multicentre study.

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Trauma & Orthopaedics, St Marys Hospital, Praed Street, W2 1NY London, United Kingdom. Electronic address:
Trauma & Orthopaedics, University College Hospital, 235 Euston Road, NW1 2BU London, United Kingdom.
Trauma & Orthopaedics, Basildon University Hospital, Basildon, Essex SS16 5NL, United Kingdom.
Trauma & Orthopaedics, Watford General Hospital, Vicarage Road, Watford WD18 0HB, United Kingdom.
Trauma & Orthopaedics, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, United Kingdom.
Trauma & Orthopaedics, St Marys Hospital, Praed Street, W2 1NY London, United Kingdom.


There is currently limited data to define reference levels for the use of ionising radiation in orthopaedic trauma surgery. In this multicentre study, we utilise methodology employed by the Health Protection Agency in establishing reference levels for diagnostic investigations in order to define analogous levels for common and reproducible orthopaedic trauma procedures. Four hundred ninety-five procedures were identified across four Greater London hospitals over a 1-year period. Exposure was defined in terms of both time and dose area product (DAP). Third quartile mean values for either parameter were used to define reference levels. Variations both between centres and grades of lead surgeon were analysed as secondary outcomes. Reference levels; dynamic hip screw (DHS) 1.9225000 Gycm(2)/70.50 s, intramedullary (IM) femoral nail 1.5837500 Gycm(2)/126.00 s, open reduction internal fixation (ORIF) clavicle 0.2042500 Gycm(2)/21.50 s, ORIF lateral malleolus 0.32250500 Gycm(2)/35.00 s, ORIF distal radius 0.1300000 Gycm(2)/56.00 s. Grade of surgeon did not influence exposure in dynamic hip screw, and was inversely related to exposure in intramedullary femoral nails. Less variation was observed with exposure time than with DAP. This study provides the most comprehensive reference to guide fluoroscopy use in orthopaedic trauma to date, and is of value both at the point of delivery and for audit of local practice.


Dose area product; Exposure time; Ionising radiation; Orthopaedic trauma; Reference levels

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