A new analysis looks at the available evidence on radiation exposure in medical imaging in pediatric orthopaedic care – and provides recommendations aimed at optimizing decision–making to reduce unnecessary exposure. The findings are being presented at a scientific exhibit at the American Academy of Orthopaedic Surgeons (AAOS) 2017 Annual Meeting.

“Traditionally, there has not been enough discussion on how we can disseminate information to best treat children with the least possible exposure to radiation,” says senior research author David H. Godfried, MD, clinical associate professor of orthopaedic surgery and pediatrics, and director of the Center for Children at NYU Langone’s Hospital for Joint Diseases. “A CT scan may be absolutely necessary for a child. But whenever there is an option, physicians should choose to obtain this information another way.”

For their research, Dr. Godfried and Ayesha Rahman, MD, a fifth–year resident in the Department of Orthopaedic Surgery at NYU Langone, reviewed peer–reviewed literature on different options in imaging technology that may be used in pediatric orthopaedic injuries, including X–rays and CT scans of the spine, pelvis, hip, knee, shoulder, elbow, hand and wrist, and foot and ankle. They then quantified the amount of radiation in each of these scans.

They subsequently identified that children who require surgery for hip dysplasia, scoliosis, and leg length discrepancy are among those most likely to undergo imaging such as X–rays or CT scans, and therefore may be among those children who are most vulnerable to exposure risk.

For example, their analysis found that children with hip dysplasia that required surgery received two times more X–rays and underwent multiple CT scans compared to nonsurgical pediatric patients, which cumulatively increased their overall risk of fatal cancer or genetic defects by less than one percent, a small but significant risk. In another finding, females with scoliosis received two times more X–rays than nonsurgical patients, amounting to twice the radiation exposure to the breasts, ovaries, and bone marrow, and correlating to an over two percent increased lifetime risk of fatal breast cancer, almost one percent risk of fatal leukemia, and three percent risk of genetic defects. Nonsurgical patients had approximately half that risk.

Based on the available evidence, the authors developed the following list of best practices that orthopaedic surgeons should follow:

• follow the “as low as reasonably achievable,” or ALARA, principle to limit exposure to parts of the body that are absolutely essential for diagnosis
• eliminate repeated exposures resulting from technical errors
• limit precise collimation to the region of interest
• limit fluoroscopy to short bursts as needed
• utilize low–dose CT protocols adjusted for the size of the patient
• limit CTs of the spine and pelvis in pediatric patients
• female patients are more susceptible to adverse effects than male patients
• children with scoliosis should have limited follow–up X–rays
• Leg length, scoliosis, and hip dysplasia (anteversion) studies should utilize EOS imaging technology rather than traditional X–rays
• X–rays are an acceptable diagnostic tool for extremities, such as the wrist or ankle
• CT scans are an acceptable diagnostic tool for triplane fractures