Fluoroscopy Principles

I would apply the ALARA principle using time, distance, and shielding. For time: I use pulsed fluoroscopy at the lowest acceptable rate (7.5-15 fps), avoid continuous screening, use last-image-hold to review images, and plan my shots to minimize total fluoro time. For distance: all staff should stand as far from the beam as practical, applying the inverse square law - doubling distance quarters the dose. Staff should stand on the detector side of the C-arm where scatter is lowest. For shielding: everyone must wear lead aprons (0.5mm Pb equivalent attenuates 95% of scatter), thyroid shields, and consider lead glasses. I would position the C-arm with the tube below the patient to direct scatter downward, collimate tightly to reduce the exposed field and scatter, and use mobile lead shields if available. I would also communicate with the team, calling out when screening so staff can step back.

For a lateral view of the femur during nailing, I position the C-arm horizontal with the tube on one side and detector on the other. The standard convention is tube posterior, detector anterior - this keeps scatter directed posteriorly away from most of the operating team who are positioned anteriorly. I would stand on the detector (anterior) side of the C-arm, not the tube side, because scatter radiation is maximum on the tube side. If I need to be on the tube side for surgical access, I ensure I'm wearing full PPE and position any mobile lead shield between me and the tube. The image intensifier should be as close to the patient as possible without being in the surgical field - this reduces magnification and improves image quality while reducing scatter. For the lateral view, I need to ensure the C-arm can clear the operating table and any traction equipment.

I would advise on several dose reduction strategies. First, use a mini C-arm if available - it delivers significantly lower dose than a standard C-arm for extremity work. Second, avoid continuous fluoroscopy - use single spot images or very short bursts. Third, use last-image-hold extensively - review the stored image rather than screening continuously. Fourth, plan your shots - position the hardware, then take an image, rather than watching the screen while adjusting. Fifth, consider if you need fluoroscopy at all - for many steps like plate positioning, direct vision may be adequate. I would also ensure the pulse rate is set low (7.5 fps is often sufficient for static assessment), avoid magnification unless absolutely needed, and collimate the beam to the area of interest. For training, I would recommend developing mental checkpoints - 'position, then check' - rather than continuous screening. Finally, wearing a dosimeter helps develop awareness of one's radiation use patterns.