Abstract
Background
Gravid females with pelvic fractures are rarely encountered by the orthopaedic trauma surgeon. The initial injury can be detrimental to the pregnant patient, but an unnecessary “second hit” from surgery could also contribute to the outcome of the fetus. Understanding the surgical risks for this unique patient population requires knowledge about the negative effects of anesthesia, surgical exposures, and radiation. Radiation levels below 5 rad are negligible to the fetus, while doses above 15 rad significantly increase the harmful fetal effects. The purpose of this study was to identify which pelvis and acetabular fracture patterns dictate dangerous fetal levels a fluoroscopic radiation.
Methods
All patients greater than 16 years of age with operative or potentially operative pelvic ring, sacrum, or acetabulum fractures treated by a single surgeon during his first five years of practice were screened for inclusion. Included patients underwent open reduction with internal fixation, closed reduction with percutaneous fixation, or exam under anesthesia with a recorded final fluoroscopic cumulative dose, irrespective of pregnancy. Excluded patients had periprosthetic fractures, associated operative femoral head fractures, pathologic fractures, patients undergoing combined ORIF/arthroplasty, revision surgery or hardware removal. Primary outcomes were intraoperative radiation dose per fracture pattern, total cumulative radiation, and miscarriage. Secondary outcomes included demographic information, fracture fixation type, and fluoroscopic radiation per percutaneously placed screw.
Results
One hundred and fifty patients were included in this study. A single eight week pregnant patient with a combined associated both column and anteroposterior compression ring injury was identified who had >5 rad cumulative exposure and a miscarriage during the acute postoperative period. Intraoperative radiation dose differed significantly between elementary and associated acetabular patterns (p = 0.0004). Isolated posterior wall fractures utilized less intraoperative radiation compared to the associated both column and transverse-posterior wall groups. Radiation exposure was less for 2 versus 3 percutaneously placed screws (p = 0.0127), 2 versus 4+ screws (p = 0.0011), but not 3 versus 4+ screws.
Conclusion
Increasing fracture complexity influences radiation exposure in pregnant and non-pregnant patients, while demographics had no influence. Isolated posterior wall fractures and 2-screw posterior ring fixation constructs provided consistently safer levels of fluoroscopic radiation. This knowledge can benefit both the surgeon and patient during the shared decision-making process.
Keywords: Pregnant patient, Pelvic ring, Acetabulum, Radiation, Fluoroscopy
1. Introduction
With only 7 % of pregnant patients being involved in major trauma, usually from motor vehicle accidents, this population is rarely encountered by the orthopaedic trauma surgeon.1 Moreover, approximately 0.3 % of pregnant patients who sustain trauma require hospital admission.2 It stands to reason that even fewer pregnant patients sustain operative pelvis or acetabulum fractures. While the initial traumatic event can be detrimental to the mother and fetus, an unnecessary “second hit” from surgery could also contribute to the patient or fetal outcome. Understanding surgical risks for this unique patient population requires knowledge about the negative effects of anesthesia, surgical exposures, and radiation to the fetus.
The fetus can be exposed to high levels of radiation from the initial Advance Trauma Life Support (ATLS) evaluation, pre- and postoperative imaging, and intraoperative cumulative fluoroscopic doses of radiation. Yet, the amount of fluoroscopic exposure dictated by various acetabulum and pelvis fracture patterns is generally unknown. Fetal radiation exposure is concerning because fetal cells divide rapidly, making them more radiosensitive and subject to higher degrees of mutation than other cells.3 The National Council on Radiation Protection has determined radiation levels below 5 rad are negligible to the fetus, while doses above 15 rad significantly increase the harmful fetal effects of radiation.4 Moreover, there is a linear dose-related association between radiation and fetal anomalies with greater than 10 rad exposure.5,6 A radiation dose between 50 and 100 rad (0.5–1 Gy) doubles the mutation rate.7 Source of radiation exposure also matters, as doses vary between radiography, fluoroscopy, and computed tomography (CT) scans. A CT scan provides the greatest amount of radiation, but the amount can change based on the machine, institutional protocol, and image type (I.e. chest, abdomen, pelvis).
The purpose of this study was to identify which pelvis and acetabular fracture patterns dictate dangerous fetal levels a fluoroscopic radiation. To our knowledge, few studies have detailed the typical amounts of fetal radiation exposure for pelvis or acetabulum fractures,8 and none have evaluated this based on fracture pattern. Characterization of fracture pattern-related radiation exposure can help justify the risk and benefits of surgery to the childbearing patient. Moreover, this knowledge can guide prudent use of fluoroscopy, when possible, for more complex injury patterns to limit fetal exposure and harm. The data presented in this study is based on the senior author's first five years of practice, during which we suspect fluoroscopic doses would likely be highest.
2. Methods
All trauma patients aged 16 years and older with acetabulum, sacrum, or pelvic ring injuries were retrospectively identified by chart review and data collected after institutional board review approval. All patients were operated on by a single fellowship-trained orthopaedic traumatologist (S.P.) during his first five years of practice, between August 2019 and February 2024. A total of 156 patients with operative acetabulum, sacrum, or pelvic ring fractures were identified at a single Level I trauma center. Included were patients undergoing open reduction with internal fixation (ORIF), closed reduction with percutaneous screw fixation (CRPF), or examination under anesthesia (EUA) requiring fluoroscopy use; were pregnant and non-pregnant, had a minimum of three months of follow-up, and had fluoroscopic records that included cumulative radiation exposure. Exclusion criteria consisted of periprosthetic fractures, combined femoral head and acetabulum injuries that needed femoral head fixation, pathologic fractures, patients undergoing combined ORIF/arthroplasty, hardware removal, and revision surgeries.
All patients underwent ATLS-guided trauma evaluation and were treated with a standardized pre- and postoperative imaging protocol. Preoperative imaging for all patients included a 5-view radiographic series and a CT chest, abdomen, and pelvis. Postoperative protocol for every patient, unless pregnant, consisted of a 5-view radiographic series and a dedicated CT pelvis. Pregnant patients received the same preoperative protocol, however, postoperative protocol for pregnant patients excluded a dedicated pelvis CT scan to limit radiation. Pre- and postoperative imaging radiation dosages for our institution are detailed in Supplemental Table 1.
Demographic variables included patient age, sex, and body mass index (BMI). Females were further characterized as being within childbearing age (12–50 years) and whether they were pregnant. Pregnancy status was determined based on beta-hCG levels, which was collected as part of the institutional policy for trauma patients of childbearing age. Obstetric consultation was obtained for any patient with a positive beta-hCG level. Postoperatively, fetus viability was evaluated by the obstetric team and further treatment was provided based on their recommendations. No intraoperative fetal monitoring was performed for our one pregnant patient since the fetal age was eight weeks.
Preoperative radiographic images were reviewed for fracture pattern classification by the primary author (Z.F.) and confirmed by the treating surgeon (S.P). All acetabulum fractures were classified using the proposed system by Judet and Letournel,9 and pelvic ring fractures using the Young and Burgess classification.10 The OTA/AO classification was also used for all acetabulum, sacrum, and pelvic ring fractures.11 Classifications proposed by Judet and Letournel and Young and Burgess are primarily used throughout the literature and were therefore used in the analyses involving injury pattern cohorts. Operative procedures included ORIF, CRPF, application of an external fixator (ex-fix) or anterior subcutaneous pelvic fixator (INFIX), or a combination of these techniques. Choice of procedure and surgical approach was dictated by fracture pattern based on the aforementioned classifications. For all cases involving isolated percutaneous fixation of the pelvic ring, the number of percutaneous screws used was recorded for each patient, which was not dependent on the screw location/style (iliosacral, trans-iliac trans-sacral, anterior or posterior column screw).
Primary outcomes included intraoperative and total radiation exposure for each acetabulum, sacrum, and pelvic ring injury subtype. Secondary outcomes included cumulative perioperative radiation exposure based on demographic parameters, procedure type, and the number of percutaneous screws in cases involving isolated percutaneous screw fixation.
Statistical analyses were performed to assess differences in radiation exposure and demographics between groups. Shapiro-Wilks testing was used to assess normality. Distributions were non-normal for all variables; thus, nonparametric statistical tests were used and continuous values were presented as median (interquartile range [IQR]). Categorical data were presented as counts and percentages. Mann-Whitney U testing was used to assess variation in medians between two groups, whereas a Kruskal-Wallis test was used to compare three or more groups. For any Kruskal-Wallis tests resulting in significance, a post-hoc Dunn's multiple comparisons test was performed to determine significant differences between individual groups. For categorical variables, a Fisher's Exact test was used to compare proportions between two groups, whereas the Chi-Square test was used for comparisons of three or more groups. Significance was determined with an alpha of 0.05. All analyses were conducted using GraphPad Prism version 10.2.0 (GraphPad Software Inc, San Diego, CA, USA).
3. Results
One hundred fifty-six patients were identified on initial chart review, six of which met exclusion criteria for reasons including periprosthetic fractures (3), pathologic fractures (1), combined acetabulum and femoral head fractures (1), and combined ORIF/arthroplasty fixation (1). A total of 150 patients were included in the study, including 55 (36.7 %) acetabular fractures, 72 (48 %) pelvic ring injuries, 6 (4 %) sacral fractures, and 17 (11.3 %) combined acetabulum-pelvic ring injuries.
Demographic characteristics of the total sample and each injury type are demonstrated in Supplemental Table 2. The average age of the total sample was 44.5 years, with the majority being male (55.3 %). Of the females, 40 (59.7 %) were of childbearing age with one confirmed pregnancy. There were significant differences in age (p = 0.0036), BMI (p = 0.0160), and the proportion of females of childbearing age (p = 0.0422) between injury types.
Intraoperative radiation dosages were significantly different between injury types (p = <0.0001). Combined acetabulum-pelvic ring injuries had the highest median intraoperative radiation dose of 13.2 rad (8.1, 24.0), followed by isolated pelvic ring injuries (7.7 rad [5.0, 12.0]), sacral fractures (2.8 rad [2.4, 3.4]), and acetabular fractures (1.8 rad [1.0, 4.1]). One eight-week pregnant patient with a combined associated both column and anteroposterior compression (APC) type pelvic ring injury was identified (Fig. 1). The patient and fetus had intraoperative and cumulative radiation dosages well above the 5 rad safety threshold in this study (total exposure of 11.35 rad). Unfortunately, the patient had a miscarriage during the acute postoperative period.
Fig. 1.
A) Preoperative 3D reconstruction images of a pelvic CT of an 8-week pregnant patient with a combined acetabulum-pelvic ring injury. B) Postoperative radiographs of the same patient demonstrating near anatomic fixation.
A breakdown of cumulative radiation dose by acetabular fracture, pelvic ring injury, and sacrum fracture subtypes is shown in Table 1. Among the isolated acetabular fractures, intraoperative radiation dose was significantly higher in associated fracture patterns than elementary patterns (median of 2.8 rad versus 1.3 rad; p = 0.0004) (Fig. 2A). Fig. 2B further illustrates the differences in intraoperative radiation dosages between acetabular fracture pattern subtypes. Isolated posterior wall fractures utilized significantly less intraoperative radiation compared to the associated both column and transverse-posterior wall groups (p = 0.0245 and p = 0.0121, respectively). In regard to pelvic ring injury subtypes, there were no differences between APC and lateral compression (LC) types for intraoperative and total radiation exposure (Supplemental Fig. 1, Supplemental Table 3).
Table 1.
Cumulative radiation dose by injury subtype.
| n | Intraoperative radiation (rad) | >5 rad total radiation dose | ||
|---|---|---|---|---|
| Pelvic ring | APC | 17 | 9.7 (6.3, 12.8) | 17 (100) |
| LC | 55 | 6.5 (4.5, 11.8) | 54 (98.2) | |
| Acetabular fracture | Elementary Patterns | 22 | 1.3 (0.4, 2.1) | 5 (22.7) |
| AC | 4 | 2.5 (1.2, 3.4) | 2 (50.0) | |
| AW | 1 | 0.6 (0.6, 0.6) | 0 (0) | |
| PC | 0 | – | – | |
| PW | 16 | 1.1 (0.3, 1.7) | 2 (12.5) | |
| Transverse | 1 | 2.5 (2.5, 2.5) | 1 (100) | |
| Associated Patterns | 33 | 2.8 (1.6, 6.6) | 21 (63.6) | |
| ABC | 14 | 2.8 (1.7, 6.4) | 10 (71.4) | |
| TPW | 10 | 5.6 (3.0, 11.2) | 8 (80.0) | |
| T-type | 1 | 15.0 (15.0, 15.0) | 1 (100) | |
| ACPHT | 2 | 7.9 (1.7, 14.2) | 1 (50.0) | |
| PCPW | 6 | 1.2 (0.6, 1.9) | 1 (16.7) | |
| Sacral fracture | U-type | 6 | 2.8 (2.4, 3.4) | 5 (83.3) |
Continuous data presented as median (IQR), categorical data presented as n (%).
“-” indicates incomplete data.
APC, anteroposterior compression; LC, lateral compression; AC, anterior column; AW, anterior wall; PC, posterior column; PW, posterior wall; ABC, associated both column; TPW, transverse + posterior wall; ACPHT, anterior column or wall + posterior hemi-transverse; PCPW, posterior column + posterior wall.
Fig. 2.
Intraoperative radiation dose by acetabular fracture A) type and B) subtype.
Dosages differing significantly between fracture subtypes according to Dunn's multiple comparison test: PW vs. ABC (p = 0.0245), PW vs. TPW (p = 0.0121).
AC, anterior column; AW, anterior wall; PC, posterior column; PW, posterior wall; ABC, associated both column; TPW, transverse + posterior wall; ACPHT, anterior column or wall + posterior hemi-transverse; PCPW, posterior column + posterior wall.
No significant differences were observed in patient age, BMI, sex, females of childbearing age, or pregnancy status between cohorts of patients who received a cumulative total radiation dose of >5 rad versus ≤5 rad (Table 2). There were, however, differences in intraoperative radiation dosages between surgical procedure types (p = <0.0001) (Fig. 3). CRPF of the pelvic ring had greater intraoperative radiation exposure compared to ORIF alone (p = 0.0001). Moreover, CRPF in combination with ORIF or ex-fix/INFIX constructs had significantly higher intraoperative dosages than ORIF and EUA alone, but not CRPF alone (Fig. 3, Supplemental Table 4).
Table 2.
Demographic characteristics among cohorts of patients that received a cumulative total radiation dose >5 rad and ≤5 rad (n = 150).
| >5 rad | ≤5 rad | P | |
|---|---|---|---|
| n | 119 (79.3) | 31 (20.7) | |
| Age (years) | 43.0 (26.0, 62.0) | 46.0 (26.0, 63.0) | 0.0908 |
| BMI (kg/m2) | 27.3 (24.4, 34.1) | 25.7 (22.9, 33.3) | 0.2652 |
| Female | 56 (47.1) | 11 (35.5) | 0.3118 |
| Female of child bearing age (12–50 years) | 32 (57.1) | 8 (72.7) | 0.5043 |
| Pregnanta | 1 (3.1) | 0 (0) | >0.9999 |
Continuous data presented as median (IQR), categorical data presented as n (%).
Among females of child bearing age.
Fig. 3.
Intraoperative radiation dose by procedure type.
Dosages differing significantly between groups according to Dunn's multiple comparison test: CRPF only vs. ORIF only (p = 0.0001), ORIF only vs. CRPF + ORIF (p = <0.0001), ORIF only vs. CRPF + Ex-fix/INFIX (p = 0.0008), CRPF + ORIF vs. EUA (p = 0.0179), CRPF + Ex-fix/INFIX vs. EUA (p = 0.005).
CRPF, closed reduction percutaneous fixation; ORIF, open reduction internal fixation;Ex-fix, external fixator; EUA, exam under anesthesia.
Cumulative intraoperative radiation dose was also compared based on the number of percutaneously placed screws in cases involving CRPF only (Table 3). Radiation exposure was less for 2 screws versus 3 screws (p = 0.0127), 2 screws versus 4+ screws (p = 0.0011), but not 3 screws versus 4+ screws (p = 0.9664). Furthermore, insertion of 2 screws had a median intraoperative radiation exposure less than the safety threshold of 5 rad, whereas insertion of ≥3 percutaneous screws was more likely to result in exposure greater than 5 rad.
Table 3.
Cumulative intraoperative radiation dose by number of percutaneous screws in cases that involved percutaneous screw fixation only (n = 59).
| 2 screws | 3 screws | 4+ screws | P | |
|---|---|---|---|---|
| n | 16 (27.1) | 25 (42.4) | 18 (30.5) | |
| Intraoperative radiation dose (rad) | 3.1 (2.8, 4.9) | 6.3 (4.8, 10.0) | 7.1 (6.4, 9.8) | 0.0011 |
Continuous data presented as median (IQR), categorical data presented as n (%).
Intraoperative radiation dosages differing significantly between groups according to Dunn's multiple comparison test: 2 screws vs. 3 screws (p = 0.0127), 2 screws vs. 4+ screws (p = 0.0011), 3 screws vs. 4+ screws (p = 0.9664).
4. Discussion
Encountering a gravid female with a pelvis or acetabulum fracture is uncommon, as was evident in this study, with only one pregnant patient needing fixation during the 5-year period. However, rare situations can benefit from studies that provide insight and guide informed decision making to achieve optimal patient outcomes. Until the early 2000's, most pregnant patients with acetabular fractures were treated nonoperatively.12 Nowadays, surgical risks are mitigated as much as possible based on gestational age and are generally accepted after a thorough discussion with the mother. With a trend toward percutaneous fixation of most pelvic ring and certain acetabular fracture patterns, surgeons rely more heavily on indirect reduction assessment via radiographic means, resulting in greater amounts of radiation exposure. Thus, awareness of the risks associated with radiation exposure in complex orthopaedic injuries is crucial for surgeons treating this vulnerable patient population.
This retrospective cohort study demonstrated that intraoperative radiation doses are closely associated with injury pattern. The safety threshold for cumulative radiation dose in this study was ≤5 rad since this amount of radiation is considered negligible to the fetus, whereas >15 rad significantly increases the rate of harmful effects to the fetus.4 Interestingly, 21 % of the study population (32/150) received a total radiation dose above 15 rad, half of which occurred in cases involving a combined acetabulum-pelvic ring injury. It is important to note that no demographic differences were observed between patients who received a cumulative dose of <5 rad versus >5 rad, further suggesting that fracture pattern influenced intraoperative radiation exposure more than patient size, sex, age or pregnancy status.
Among isolated acetabulum fractures, intraoperative radiation exposure was significantly less for elementary acetabular patterns compared to associated types, which indicates a predictable relationship between reduction difficulty and greater radiation exposure. T-type, anterior column-posterior hemi transverse, and transverse-posterior wall patterns had the greatest intraoperative radiation exposure, respectively, although the former two patterns were among the least common to occur. Meanwhile, posterior wall fractures were the most common subtype and demonstrated significantly less intraoperative radiation exposure compared to nearly all other types. This is likely due to the ability to utilize direct reduction techniques for most posterior wall fractures, depending on the presence of marginal impaction. Based on these findings, isolated posterior wall patterns may be safely treated in the pregnant patient population. In addition, posterior wall fractures offer the added benefit of operating in either the prone or lateral decubitus positions, with lateral decubitus being ideal for gravid females by positioning the uterus off the underlying vasculature.
Use of newer percutaneous techniques to fix pelvis and acetabulum fractures were popularized in the late 1990's and early 2000's13, 14, 15 due to their ability to limit the need for large open procedures and increased blood loss, which may sound appealing to the pregnant population. However, placing a large diameter screw with precision through a narrow osseous fixation pathway could require large quantities of fluoroscopic radiation.16 Obstacles like abdominal gas, osteopenic bone quality, and fetal structures within the pelvis can further limit the surgeon's ability to safely identify the necessary screw pathway.
Nearly 100 % of the pelvic ring injuries treated operatively in our study had >5 rad in total exposure, regardless of the type. There was no significant difference in intraoperative radiation between APC and LC types, likely because both were treated via similar methods of CRPF. However, the number of percutaneous screws inserted did influence the intraoperative radiation exposure. There was a significant difference between inserting 2 versus ≥3 screws, indicating that a safe fluoroscopic level of radiation can be obtained with a 2-screw construct, but not necessarily for constructs requiring 3 or more screws. This should not deter the surgeon from utilizing the appropriate construct needed to provide adequate pelvic stability, but should help encourage a thorough patient discussion regarding fetal risks and benefits of the procedure.
In the most similar study to date evaluating the in-utero radiation exposure in pregnant patients undergoing acetabulum surgery, an eight-patient case series demonstrated safe use of intraoperative fluoroscopy in pregnant patients. All eight fetuses remained viable and were brought to term.8 However, this study involved minimal variability in the fracture patterns evaluated, including four isolated posterior wall fractures, three transverse-posterior wall fractures, and one posterior column fracture. Moreover, their patients received an additional postoperative CT scan bringing their cumulative dose to >5 rad, which furthers the notion that excessive imaging can be a major factor in total exposure and should be limited in the pregnant population.8
The one operatively treated pregnant patient in our study had a spontaneous abortion during the acute postoperative period, which was likely multifactorial and could have been influenced by a combination of the initial trauma, fetal stress from anesthesia, surgery, and radiation exposure. Generally, fetal risk with radiation exposure in the range of 5–15 rad is unknown, however, there is evidence of a linear dose-dependent association with fetal anomalies.5,6 The pregnant patient in this study had a total radiation exposure of 11.35 rad which is approaching the threshold of potentially harmful fetal effects. The injury pattern consisted of an APC type pelvic ring injury and an associated both column acetabulum fracture, which is a challenging injury that can require significant fluoroscopic doses to obtain anatomic reduction and fixation. A postoperative CT scan of the pelvis was avoided in this patient to reduce further radiation exposure. Although several studies demonstrate safe treatment of pregnant patients with acetabulum or pelvic ring injuries,8,12,17,18 our findings suggest that increased fracture pattern complexity results in greater fluoroscopic and total radiation exposure, with potentially harmful fetal effects.
Spontaneous abortion can result from various factors, including chromosomal abnormalities, maternal age, previous pregnancy loss, thyroid disorders, pre-gestational diabetes, congenital uterine anomalies, exposure to environmental toxins such as lead, mercury, organic solvents, and smoking and alcohol use.19 In trauma scenarios involving pregnant patients, it is crucial to consider these risk factors, as well as the potential impacts of the trauma itself, surgical interventions, and associated stress. Regarding risks of trauma on the fetus, factors such as placental injuries, depressed skull fractures, and maternal hypovolemia may contribute to fetal demise.20 To minimize fetal radiation exposure during operative management of pelvic ring and acetabular injuries, alternative imaging modalities such as ultrasound or magnetic resonance imaging can be employed when feasible. Additionally, utilizing external fixation devices or opting for non-operative management in select cases may reduce the need for intraoperative fluoroscopy, thereby decreasing radiation exposure to the fetus.20
This study is not without limitations. The retrospective nature of the study offers potential for selection bias; however, this is unlikely since all patients with operative pelvis or acetabulum fractures during the study timeframe were included. Also, total cumulative radiation dose for all patients did not include additional imaging outside of the initial trauma workup or orthopaedic care specific to their pelvic or hip injury. Moreover, it is possible that a percentage of subjects presented with an associated hip dislocation and received additional imaging (post-reduction radiographs and CT scan) to confirm successful closed reduction and rule out intra-articular fragments. These additional radiographs and associated radiation doses were not included since it represented such a small proportion of patients. The greatest limitation is that the data is intended to be generalized to the pregnant population despite having only one pregnant patient in the study. Nonetheless, the results clearly demonstrate that with increased fracture complexity, the amount of fluoroscopic radiation exposure increases and can be harmful to the fetus. Moreover, this study proves that certain fracture patterns are consistently “safe” to fix in terms of fluoroscopic threat to the fetus, such as isolated posterior wall fractures.
Despite its limitations, this retrospective cohort study of 150 patients has several strengths. It was designed to include data from a single fellowship-trained traumatologist in his first five years of practice, which intuitively would represent a timeframe during which fluoroscopic exposure would be the largest. Moreover, the utilization of a single surgeon's experience ensures standardized techniques and fixation constructs throughout the data collection period. This was a relatively large study population for a single surgeon and included a wide variety of fracture pattern types based on the Young and Burgess, and the Judet and Letournel classifications. Despite an increase in motor vehicle accidents over the years, rates of acetabulum injury patterns appear consistent throughout much of the literature.9,21 Our study showed fracture pattern incidence similar to previous literature, further supporting the clinical relevance of our findings.
5. Conclusion
The rare pregnant patient with an operative acetabulum or pelvic ring injury requires a greater understanding of the fluoroscopic risks to the fetus. Increasing fracture complexity dictates larger amounts of radiation exposure in pregnant and non-pregnant patients, while sex, body habitus, age, and pregnancy status have less of an influence. Isolated posterior wall fractures and 2-screw pelvic ring fixation constructs provided consistently safer levels of fluoroscopic radiation, well under the 5 rad safety threshold used in this study. This knowledge can benefit both the surgeon and patient during the shared decision-making process.
CRediT authorship contribution statement
Zachary Fulton: Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Samuel Eaddy: Methodology, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Seth Phillips: Conceptualization, Supervision, Project administration, Writing – review & editing.
Consent statement
Patient consent was not obtained due to the minimal risk associated with this retrospective review. A waiver of HIPAA Authorization was approved by the Institutional Review Board prior to initiation of the study.
Ethics statement
Ethical clearance was obtained from Institutional Review Board prior to initiation of the study.
Source of funding
None.
Declaration of interest
The authors report no conflicts of interest related to this work.
Acknowledgements
None.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2024.102899.
Contributor Information
Zachary Fulton, Email: zwfulton@mercy.com.
Samuel Eaddy, Email: seaddy@mercy.com.
Seth Phillips, Email: sphillips@mercy.com.
Appendix A. Supplementary data
The following are the Supplementary data to this article.
figs1.
Cumulative radiation dose by pelvic ring injury type.
APC, anteroposterior compression; LC, lateral compression.
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