WORK MANUAL FOR

STUDENTS AND
TECHNICIANS IN
RADIOIMAGENOLOGY WITH
C-ARC
Author: TSU José David Fonseca Rivero
 GRATITUDE

After so many years of work I have to give thanks first to the training that my
parents have given me for many years and who are responsible for all my academic
success. My grandmother Berna, who with love, patience and sweetness, over the
years, shaped my behavior as a human being and continues to do so to this day at 94
years old. To my family, aunts and uncles who, in recent years and without your
support, it would not have been possible to get through the difficult times we
experienced as a family. To my Kati because without her and her drive day by day it is
not possible since we know that we are not perfect but we are not looking for
perfection to be happy but rather we are happy without being perfect and for the
greatest gift that life gave me my Dear Miranda, who is my sun in the morning, in the
afternoon and at night, who is my joy, my driving force in life so I can be the best dad,
like my father was for me, and each of those people as my Colonel Juan, for being a
second father, a counselor and a right hand, to my DaFoimagen boys for being fighters
and loving this profession as much as I love it and this job that can be an example that
imaging professionals, technicians university graduates or graduates in radioimaging
we can be great professionals.

p. 1
 The discovery of

black cardboard. By replacing the fluorescent screen with a

photographic plate he was able to record the existence of this a
radiation. By placing a piece of platinum on the plate and exposing
it to
A thearea
clear radiation source,
appeared on the plate, drawing the area where the platinum
had absorbed the radiation. This unexpected discovery was reported by
Roentgen by placing his wife's hand on a case containing a photographic
plate and making a 15-minute exposure. The bones looked white on the
developed plate, contrasting with the flesh surrounding it, which looked
black. , shortly after he prepared a short manuscript entitled ON A NEW
KIND OF RAY: preliminary communication that he presented at the
Physical Medical Society of Würzburg on December 28, 1895. In this paper
he described the generation of these x-rays and discussed the
transparency of almost all materials with this radiation.

It should be noted that among the advances that allowed this

discovery is the x-ray image intensifier, invented in 1950, which allowed
the images to be observed directly on a TV monitor, under normal light
conditions, to then record them, with a conventional camera, later video
cameras and charging devices were included to obtain images

Surgical radiology and its equipment are of great help to medicine

since through them they simplify and change many old work protocols
since with the real-time image they can be sure of the success of the
surgery and making surgical wounds very small, helping the rapid recovery
of patients and reducing surgical times.
 Current imaging technicians must be prepared today to handle this
equipment.
C-ARCH

Since Thomas Edison invented fluoroscopy in 1896, it has been a

very important tool in the practice of radiology, the fluoroscope is used for
dynamic studies. During fluoroscopy the radiologist will observe a
continuous image of the movement of internal structures while the x-ray
tube provides the energy.

In fluoroscopy, a constant beam of x-rays is used to evaluate

dynamic processes such as diaphragmatic excursion; it is also frequently
used for angiographic or interventional procedures, such as the placement
of feeding tubes or drainage catheters. It continues to be a modality
frequently used in evaluations of the upper and lower digestive tract, such
as the barium enema, the joints, and the spinal cord, such as in the case of
myelography after lumbar puncture. Recently, direct digital detector
systems have been introduced, such as CCD charged coupled divices,
matrix photonic detectors, which are beginning to replace many of the
components of fluoroscopic equipment.

[Image from ccd charge video camera.]

The fluoroscopy applied to visualize blood vessels is called

angiography and it has two main areas: neuroradiology and vascular
radiology. These areas of angiography are known as interventional
radiology.

The image shows a schematic of a fluoroscopic image acquisition

system. The x-ray tube is usually located below the patient's stretcher, the
image intensifier and other detection devices are located above the
patient's stretcher if required by the technician. Some fluoroscopes have
the tube above the table and the image receiver below the patient table.

There is equipment that can be operated from outside the X-ray

room. There are many different arrangements of fluoroscopy and the
radiographer must be familiar with each of them. During image-intensified
fluoroscopy, the x-ray image is displayed on a television monitor.

During fluoroscopy the x-ray tube operates at less than 5 MA. Despite the
low level of milliamps. The patient dose is considerably higher during
fluoroscopy than radiological examinations because the x-ray beam
irradiates the patient for a period of time.

In this manual we will be detailing the projections and positions

performed with the image intensifier in the different surgeries and
procedures, both percutaneous and open.

In 1950, the first arc-shaped image intensifier was created where the
x-ray tube was linked to the image intensifier by a c and through a current
key it was linked to a video monitor where the x-rayed image was
observed.

The x-ray tube does not have any changes compared to conventional
or digital radiology equipment where we have the most important change
is the image intensifier tube where through
 fluorescent screens where electromagnetic waves are exchanged
into photons of light to be taken by the charged CCD video screen and then
sent to the video monitors and be viewed.

1.000 50
photons /7 photo-
A of light (/ electrons 3,000 photons

(:0 1
X rays // of light
incident

\ Match
\ output
Phosphorus Photocathode
input

[Image of the intensifying effect of electrons by photons of light.]

In its external part, the c-arm is made up of several work elements

such as a command control where the imaging technician can modify the
technical parameters of the image through the manual trigger button,
modifying the Kv and the Ma of the shot, as well as the The technician can
use the equipment's collimators to reduce scattered radiation and
delineate the area of interest.

The equipment's command control also has commands to rotate the

image for the surgeon's comfort depending on the angle required.
 In the next part we will be explaining in detail the use or function of
each of these keys or buttons for your knowledge.

This part of the command control we can rotate the image from right
to left and from left to right.

The image of the arrows with the circle in the middle can silence the
alarm that tells us that we have 5 minutes of fluoroscopy.

In the image of the triangle, both the one that is located face down and
face up, we can raise and lower the c throughout its entire length.

[At the top of this image we have the kv and mA display that is being
used]
In the upside down triangle we can change the equipment mode
from automatic to manual.

In the buttons located below the screen where the initials kv are, we
can increase or decrease the kv according to the technician's criteria.

In the buttons located below the screen where the initials MAS are,
we can increase or decrease according to the technician's discretion.

In the management of the C-arm it is very important in the operating

room area at present, different techniques and surgeries that require its
uses for the benefit of the patient and their recovery, since 1950 the date
where the first C-arm was created is They have been developing
increasingly modern equipment.

For some years now I have been working with this great team in the
operating room area in Valencia, Venezuela, observing and concerned
because the majority of professionals do not leave with adequate training
from the university centers of the country, I developed this manual for
information and studies of the different colleagues.

This manual is comprised of graphite-drawn images of the

positioning of the patient's cy-arc on the surgical table where the
technician will observe the different work possibilities both in drawing and
its theoretical explanation of its behavior as well as its work within the
operating room area.

There are different specialties that require the use of the C-arm and
adequate training of the imaging technician is required for the proper
handling of the equipment and for it to actually be a benefit and not a
complication at the time of performing the surgery.
Most frequent errors by the imaging technician
In the handling of the c-arm
Regularly at work we are exposed to many setbacks and making
mistakes during surgery both due to the handling of the equipment and
the movement of the technician in the surgical area. The movement of
equipment from one place to another within the operating room requires
great care since many of the places are sterile and touching them with
unprotected equipment contaminates the area and must change the
affected area.

Another of the most frequent errors is not placing the equipment in

the ideal place before starting the surgery since if they are not well located
when viewing the image or moving the c-arm we may have problems.

TO

When handling the image we must be very careful since when

creating the image in real time and with movement of both the arch and
the equipment carriage we may lose the image or not have the image
centered on the screen.

The lack of experience when entering the operating room due to the
lack of information in books, articles or magazines since the majority of
our work as technicians is the manipulation of our equipment and as
students we do not have much possibility of having many contacts. with
tomographs, resonance equipment, nuclear medicine and the c-arm, this
situation is one of the problems of

our students as a profession and the lack of institutions that help with
training.

At the current time in 2012, the massification of the degree

program in universities in Venezuela has created the collapse of the
centers for the practice of our students and this has as a consequence that
when they graduate from the different houses of study.

It is also very important as professionals in the area of imaging to

inform our co-workers, both doctors and nurses who share our profession
in the surgical area, through talks and scientific events, the physical effects
of the radiation used in this case, the c-arm, the amount of electrons that
we handle since they are not powerful enough to create cellular damage.
Many times we make mistakes due to little anatomical knowledge
since the radiology technician in the operating room does not have a
radiologist at his side and on multiple occasions the technician has to
advise the surgeon on radiological criteria.

The lack of experience in these cases does not facilitate the

performance of the technician in the surgery and the work of the surgeon
since instead of being an element of help it becomes a problem during the
surgery, since the doctor has the experience of the technician. in the
management of the C arch and management in the operating room for the
benefit of the patient.
 C-arm in the intraoperative cholangiography study

Both laparoscopic and open

The position of the c-arm should be parallel to the patient and the monitor
should be located facing the main surgeon, the image intensifier tube should be
located in the upper part of the c and the x-ray tube should be located in the upper
part of the c-arm. At the bottom of the c, the technician must locate the c in the
patient's right hypochondrium and must be prepared so that when the surgeon injects
the iodinated contrast medium into the bile duct, the shot is fired to observe both the
cystic duct and the common bile duct

The technician must take as an initial image reference the tip of the clamp
where the catheter is located since through it the contrast medium begins its journey
through the bile ducts.

It is recommended to start with automatic triggering and switch to manual

triggering at the technician's discretion.

The technician must save the images at the time of the study since he must print
them to have the physical support of the same.

[Image of the patient's cy-arc positioning in the intraoperative cholangiography

study.]
[C-arm image of bile ducts in procedure through laparoscopy].
 Positioning of the patient's cy arch in urological surgery
ureterorenoscopy.

The patient will be in a gynecological position with legs, the

surgeon's position will be between the patient's legs, the c-arm equipment
monitor must be located on the side of the patient's pathology, for
example, if the pathology is of the right ureter, the monitor must go on the
right side of the patient, and the c-arm should be located on the opposite
side to the pathology.

The imaging technician must place the arch carriage at a distance

that can cover between the bladder and the kidney being studied without
having to move the arch carriage in all movements.

You will only have to move the c from cephalic to caudal, since this
surgery is purely percutaneous, the imaging technician must have great
skill at the time of the study since the urological surgeon will be guided
through fluoroscopy during most of the surgery.

The imaging technician must ensure that the surgical table where
the study is to be performed is radiolucent, since if not, the image will not
be obtained and the patient must be moved to a height on the table so
that the c has no problem moving underneath and through. on the table.

In this study, the urological surgeon will pass a working guide from
the bladder to the kidney fluoroscopically, then through the urological
working guide he will move a dilating balloon until the urinary tract is
dilated.
In this case, after dilating the ureter, an endoscopic urological instrument
called a ureterorenoscope will be placed until the lithiasis is located.

EG2..2

[Image of patient and arch position in ureterorenoscopy urological

surgery.]

[Image of proximal left ureteral lithiasis]

 [Positioning of the patient's cy-arc in percutaneous renal
surgery]

The patient will be in the first part of the surgery supine in a

gynecological position, the urological surgeon will be between the
patient's legs, the c-arm will be on the side of the kidney to be punctured
and the monitor on the opposite side.

The first part of the surgery, the C-arm technician must guide the
urologist through the ureter with a pyelography to paint the urinary tract
and be able to place the urological guide that will be located from the
urinary bladder

[Image of percutaneous renal puncture guided under fluoroscopy.]

An
To the kidney, after passing the urinary guide, the urologist will pass a dilator balloon
to the proximal part of the ureter.

After placing the dilator balloon, the patient must be placed prone with a slight
inclination of 30°. The C-arm technician must place the equipment parallel to the
kidney to be punctured by the urologist with the image intensifier tube on top. of C
and the x-ray tube at the bottom, to be able to move the equipment under the surgical
table and thus be able to perform the lateral projection of the kidney to be punctured.
The anteroposterior projection refers to the direction of the needle and the lateral
projection gives the depth of the needle in the abdominal area.

The technician in charge aims to perform dynamic images in both AP, lateral
and oblique projections in real time, the image of the kidney with the pathology,
painted through contrast medium looking for the location of the renal calyces.

[Image of the patient supine, arch position both AP and lateral with respect to the
kidney to be punctured.]
[Image of obese patient for percutaneous kidney surgery]
 C-arm and surgery patient positioning
cervical spine

The C-arm should be placed on the left side in relation to the patient who is in a
supine position with hyperextension of the cervical spine. The monitor should be
located where the surgeon can comfortably and directly observe the monitor. The first
image of the surgery is a reference image to program the surgical incision.

During surgery, the doctor will ask the technician to present images to locate the
vertebral space of interest since the entire surgical team must be sure that they are
operating on the pathological vertebral space.

To avoid the double plate image, the technician will place the C in a parallel
position to the plate to be worked on. If the double plate image persists, the technician
must move the C carriage from right to left until obtaining the image of a single
vertebral body.

[Image of the patient supine and c under the table in a lateral position to observe the
cervical spine.]
[Lateral cervical spine image with surgical space marker]

Intervertebral disc Annulu

s
fibrosu

nucleus
pulposu Spinal
s cord

transvers Upper articular

e process
facet
Spinous apophysis
Positioning of the patient and the arch in dorsal
column surgery.
 The patient must be positioned in the ventral ulna position, the
surgeon will perform the posterior approach, the imaging technician must
provide a starting image to mark the approach of the surgical incision in a
lateral projection after having marked the vertebral space of surgical
interest, that is This step is very important because it will precisely indicate
the start of the surgery.

After performing the surgical approach, the doctor will ask the
imaging technician to provide an image in a lateral position to certify that
it is located in the pathological vertebral body.

The imaging technician must place the C under the table completely
parallel to the pathological vertebral body to avoid a double plate image of
the vertebral body. In case of obtaining a double plate image, the
technician must move in a cephalocaudal movement to correct the image
of the vertebral body obtaining the best result from it.

In the c position to give an AP image, the image intensifier tube and

the x-ray tube must be positioned at 90°, taking its spinous process as a
reference, if the vertebral body is rotated to the right or left. The imaging
technician must move at hour 3 or hour 9 until modifying the image of the
vertebral body, obtaining a true AP of it taking as reference the image of
the pedicles and the distant spinous process x taking the transverse
processes as reference, it is very important That the spinous process is in
the center of the plate, this will indicate to the surgeon that it is a real
image.

When placing screws in the plate, the skill of the technician with the
C-arm is very important since the procedure that the doctor performs will
depend on the image quality that the technician offers to safely place the
screw in the pedicle of the vertebra and You must rotate the C both at
hour 12 or 6 and at hour 9 and hour 3 in this way giving direction and
depth to the image of the screw.
 The technician must place the image intensifier tube towards the
head and that of the patient or hour 12, also called the Fergurson
projection, and the x-ray tube towards the patient's legs or hour 6.

[Image of the patient supine and the arch in position above the patient.]

[Image of the patient supine and image of the c-arm in PA position and in
lateral position under the table.]

Patient and arch positioning in lumbar spine surgery

The patient located in a prone position, the surgeon will perform the
posterior approach, the imaging technician must provide a starting image
to mark the approach of the surgical incision in a lateral projection after
having marked the vertebral space of surgical interest, it is very important.
this step because it will accurately indicate the start of surgery.
 After performing the surgical approach, the doctor will ask the
imaging technician to provide an image in a lateral position to certify that
it is located in the pathological vertebral body.

The imaging technician must place the C under the table completely
parallel to the pathological vertebral body to avoid a double plate image of
the vertebral body. In case of obtaining a double plate image, the
technician must move in a cephalocaudal movement to correct the image
of the vertebral body obtaining the best result from it.

In the c position to give an AP image, the image intensifier tube and

the x-ray tube must be positioned at 90°, taking its spinous process as a
reference, if the vertebral body is rotated to the right or left. The imaging
technician must move at hour 3 or hour 9 until modifying the image of the
vertebral body, obtaining a true AP of it taking as reference the image of
the pedicles and the distant spinous process x taking the transverse
processes as reference, it is very important That the spinous process is in
the center of the plate, this will indicate to the surgeon that it is a real
image.

When placing screws in the plate, the skill of the technician with the
C-arm is very important since the procedure that the doctor performs will
depend on the image quality that the technician offers to safely place the
screw in the pedicle of the vertebra and must rotate
 the C both at hour 12 or 6 and at hour 9 and hour 3 in this way giving direction and
depth to the image of the screw.

The technician must place the image intensifier tube towards the head and that
of the patient or hour 12, also called the Fergurson projection, and the x-ray tube
towards the patient's legs or hour 6.

If the patient is located supine in an anterior approach to the lumbar spine, the
same technical procedure will be performed in the management of the C-arm
equipment, obtaining posteroanterior images since the x-ray tube will be located
under the table, influencing the radiation beam through the patient's dorsal area and

sides.

[Arch position above patient for spine .]

[C-arm above the table]

 [C-arm under the table]

[Position of the patient prone and arch position under the table and in
anteroposterior and lateral projection with biplanar equipment.]

16.09.1
10.2

[Image of interdiscal prosthesis l5 s1 in fergurson projection .]

 Positioning of the patient and the c-arm in humerus surgeries

There are different techniques for trauma surgery of the humerus, one of
the most used is surgery with the patient in a beach chair position on the
surgical table. The technician must place the arch just behind the patient's
head, placing it above the shoulder. of the patient, the image intensifier
tube will be at the back of the patient and the internal rotation as in
external rotation, the position of the upper limb is very important to be
able to give a true projection.

Regularly, before each intervention, the technician must take into account
the space where the equipment will be located and the space where the
monitor will be located so as not to have any inconvenience during the
intervention and thus optimize both the surgical time and the anesthesia
time.

[Image of the patient in the beach chair position and the c-arm in the AP
position behind the patient.]

■■

Patient and c-arm positioning in elbow surgery

The patient in this surgery will be placed supine and the surgeon will
position the patient's elbow as warranted. The technique used in the
surgery is usually placed in internal rotation and abduction is performed to
acquire the image with the c-arm. In this surgery the technician must place
the arch on the same side of the affected elbow and the video monitor on
the side. opposite so that the surgeon has it in front of him.

The image intensifier tube should always be located in the upper part of
the c and the x-ray tube in the lower part of the c, the technician must
image the entire limb since in many of these cases there are fractures plus
dislocations. .
 Positioning of the patient and the c-arm in forearm surgery and
hand

The patient is in a supine position and a radiolucent hand table is regularly used to
perform the surgery. The technician must place the C cart on the side where the
patient has the injury and the monitor on the opposite side facing both the surgeon
and the technician.

The location of the C-arm carriage must be ideal to be able to take an image of the
entire forearm both proximally and distally. It is very important that the technician
maintains the arch at 90 degrees to be able to obtain a true AP image of the forearm
and the surgeon will rotate the forearm to obtain a lateral image of it, with the c-arm
we can work in the area of the forearm in two modalities or work methodologies such
as open surgery or percutaneous surgery, in open surgery the technician will have less
prominence since the surgeon will make an incision in the patient's skin or a wide
approach to perform the surgery, in percutaneous surgery the technician is the
protagonist along with the arch and the surgeon since in this work methodology the
doctor will clearly depend on fluoroscopy to perform surgery.

In hand surgery, the percutaneous technique is not used much due to small phalanges
and fractures and very small wires or plates are usually placed where the c-arm
performs a very important job to see the alignment of the fracture as in most cases.
cases in traumatology.
opaque bodies

gkat

[The first radiology equipment in the world.]

[Modern c-arm equipment year 2013.]

 Positioning of the patient and the c-arm in hip surgery and
pelvis

There are different techniques and methodologies for working on the c-

arm in hip surgery, everything will depend on what the surgeon does at
the time. You can work with techniques for DHS, TOTAL PROSTHESIS,
PARTIAL PROSTHESIS, which are the majority of the materials.
osteosynthesis placed in the hip.

In hip surgery with DHS, the technician and the c-arm are a great
protagonist since a good part of the surgery will depend on the image of
the c-arm. In this procedure, the technician must place the c-arm between
the legs of the patient. patient who will be placed in a supine position on a
traction table, the technician will place the c-arm carriage on the leg
contracted to the hip to be operated with an inclination of 50 to 60
degrees, the image intensifier tube always will be placed at the top of the c
and the x-ray tube at the bottom, it is very important that the technician
take the distance between the arch carriage at c and the hip so that he has
the image in the oblique and ap projection of the same.

The function of the c-arm in this surgery is to serve as a guide when the
surgeon passes the guide wire through the femoral neck in the AP
projection since in this image the doctor obtains the depth and in the
oblique projection the direction can be observed. Ideally, it should be x
distant from both the internal and external cortex of the neck of the
femur. If this does not pass, the plate screw may be poorly placed and the
fracture will not be stable.
 [Image of the patient on a traction table and the c-arm in apical
projection.]

[Image of the patient on a traction table and the c-arm in an oblique

projection between the patient's legs.]

[Image of DHS device in ap projection .]

 [Image of the guide wire in the patient's femoral neck in AP view.]

In hip surgery with prosthesis, the technician must position the arch
according to the doctor's methodology. If the patient is on the lateral ulna
or supine ulna, this surgery does not depend primarily on the c-arm, it is
only used at certain moments of the surgery. .

The imaging technician must place the C-arm lateral to the patient and
place the C above the patient if he is located laterally in order to give the
doctor an AP view of the hip. It is very important that the technician gives
him a reference to the pubis of the patient compared to the head of the
prosthesis so that it is not angulated compared to the pelvis and to
prevent the patient from having a shortened limb.

[C-arch above the surgical table.

[Partial hip prosthesis in Ap view with proximal femur fracture.]

In the event that the patient is supine, the imaging technician must place the c-arm in
AP projection and provide a panoramic image of the patient's hip so that the doctor
can do an intraoperative check of the surgery and rule out that the prosthesis this
lujada

[Patient position on traction table for hip surgery]

[Image of patient position and c-arm for hip prosthesis.]

[Image of dual plane c-arm in position for hip surgery.]

 InPositioning
pelvic surgery, depending
of the on the
patient and thepatient's
c-arm in pathology, the technician
femur surgery
imaging specialist will use different projections to obtain the best image
For example, if the pathology is of the sacroiliac joint,
indicated projection is the input projection, this projection is
performed by tilting the image intensifier tube and the tube at 12 o'clock
x-ray at hour 6 also called open projection.

If the patient's fracture is located in the patient's pubis

The technician should tilt the intensifier tube towards 6 o'clock.
image, also known as output projection.

Depending on the surgical approach, the patient may be positioned

supine or prone position as required by the doctor.
In femur surgery, according to the technique and type of surgery
performed, the patient will be placed on the surgical table. In femur
surgery with a locked nail, the patient will be in a lateral decubitus
position, the C-shaped arch will be placed facing the patient. above to be
able to give the AP image of the femur.

The locked nail technique is purely percutaneous and the success of the
surgery depends greatly on the skill of the c-arm operator since he will
have to provide an image of the fracture focus and the guide that the
orthopedic surgeon passes through the canal. Due to the position of the
patient, which is lateral ulna, the arch must be above the table to be able
to face the patient and give an anteroposterior image of the femur.

The patient can also be in the supine position with a traction table and the
technician must place the c-arm in a 90-degree position with the image
intensifier tube on top and the x-ray tube on the bottom.

The patient in this position will have traction exerted by the

surgical table until the fracture is aligned and the
traumatologist will perform the reduction procedure through
the image obtained radiologically.
Likewise, the position
Positioning of the of the cart
patient andwill
thebec-arm
half of
in the patient's
femur surgeryfemur so that
the radiologist can give the image with the perpendicular movement of
the c from distal to proximal anatomically from the femoral head to the
knee.

To obtain a lateral view of the femur when the patient is on the traction
table, the technician must rotate by placing the arch between the
patient's leg, the patient will be attached to the traction table, there will
be no movement and the leg must be in a neutral position with the
fingertip at 90 degrees, this projection is very important as it will tell the
doctor if the screws used in the plate are inside the bone and the
anteroposterior projection will give the depth of the screw.
 Patient and c-arm position in knee surgery

In knee surgery, the patient will be supine with extension of the lower
limb. The patient may be placed with a traction table or on a surgical bed
without traction. The position of the arch must be placed in a 90-degree
position to obtain the anteroposterior image of the knee. knee, the
radiology technician will place the equipment on the opposite side to
where the main surgeon is to facilitate the work of the medical and
nursing team during the surgical intervention.

The reference image should be the break in the center of the image and
the femoral condyles well aligned both internally and externally.

[C-Arm Lateral Knee Image]

Depending on the anatomical variants and the age of the patient, the
imaging technician must give the best image to the surgeon, always with
the area of interest in the center of the screen.

The intensifier tube should go at the top of the c as close as possible to the
patient's knee to have a sharper image, reduce secondary radiation and
not cause burns from the heat emitted by the x-ray tube.

The lateral projection e technician should rotate the c under the surgical
table with the intensifier tube on the side of the arch carriage in c and
the x-ray tube
Patient andonc-arm
the opposite
positionside, theand
in tibia doctor should
fibula slightly bend the
surgery
knee to place it in the line between the x-ray tube and the image
intensifier tube.

The condyles must be aligned to obtain the ideal image of the knee,
especially in tibial plateau surgery or femoral condyles with screws to be
sure that the instruments are well located.
This surgery is one of the most common in the area of traumatology due
to the large number of accidents, the patient's position is supine, the c-
arm must be located on the opposite side of the leg where the surgery is
to be performed, The imaging technician must locate the intensifier tube
at the top and the x-ray tube at the bottom.

Depending on where the fracture is located, the technician must place the
image in the middle of the screen. The arch carriage is regularly placed in
the middle third of the tibia to be able to mobilize the c towards proximal
or distal if required by the doctor. .

Regularly, in tibia or fibula surgery, the surgical approach is from the

external side. The radiology technician, moving forward and backward,
must cover both the external and internal cortex of the tibia.

In the lateral projection, the radiologist technician must rotate the C and
the surgeon under the table and the surgeon must make a small flexion of
the tibia to perform the usual lateral image, trying to ensure that the
intensifier tube is located as close to the area of interest.

In fibula surgery, the same parameters are followed as in tibia surgery,

both in the front image and in profile. The variants are very few, only in
the mortise projection, which tilts the ankles by 15 degrees in internal
rotation to see the opening of the joint.

It is very important in ankle surgery that in the lateral projection the

malleoli are completely aligned to perform a true lateral projection.
 C-arch management
Patient protocolinintibia
and c-arm position footand
surgery
fibula surgery

In Halux Valgus surgery it is one of the few surgeries where the intensifier
tube goes in the lower part of the c so that it works as support for the
patient's foot and the foot can be observed in a life-size image.

At the time the surgeon performs the halux osteotomy, the technician
must give a pulsed fluoroscopy image so that the surgeon can observe the
phalanx osteotomy.

In plantar spur surgery, the surgeon will place the intensifier tube on top
of the tube in lateral projection to adequately observe the calcaneal bone
where the surgeon with percutaneous opening in the plantar region will
approach to address the calcaneal spur.

In phalangeal fracture surgery, the AP image should have the intensifier

tube as proximal to the foot as possible to have a real image since in this
case the surgeon needs to adequately observe each phalanx to reduce the
fracture.
 Radiation protection with c-arc

Radiological protection in the world is one of the biggest headaches since

it seeks to protect occupationally exposed personnel as well as the public
and the patient. Every radiological study must be justified by a medical
order since we try to avoid deterministic and stochastic effects. .

In the operating room, protection has to be more important since the

person is inside the operating room working with the equipment without
any leaded barrier except for leaded overalls or aprons and thyroid
protectors.

C-arc equipment has low radiation doses since the maximum MA is 5, but
this does not indicate that personnel should not be protected. It is
important to remember that the patient has no dose limit since it is
justified in favor of a good diagnosis and therapeutic technique.

The position of the equipment makes the difference in those dealing with
scattered radiation since with the appropriate position of the x-ray tube
we can prevent the scattered radiation from being in the most protected
area of occupationally exposed personnel such as doctors, nurses and
technicians.

The annual dose limits for personally exposed people are 20 mSv, and this
is measured thanks to personal dosimeters that in each surgery must be
located below the staff's breastplate.

It is important to remember that the dosimeter does not measure the

radiation that personnel accumulate in the body but rather the radiation
dose they were exposed to during a certain time.

The imaging technician should only give the surgeon an image only when
necessary. This helps reduce the dose rate in each intervention. In
percutaneous surgeries, the radiation dose is higher since the intervention
depends 100% on the fluoroscope, such as in percutaneous renal surgery.
Other parameters in surgery that increase scattered radiation and radiation dose are
the weight of the patient, the greater the weight, the greater the radiation dose in the
primary beam and the greater the scattered radiation.

The position of the work equipment is very important to avoid being in the direction of
the scattered radiation, all personnel must be on the side of the image intensifier tube
since the scattered radiation collides against it and is shot towards the opposite side, to
the By not having personnel on the side of the x-ray tube, we prevent scattered
radiation from harming the personnel in the surgical area.

Lead aprons, breastplates or lead mandrels should never be stored folded after surgery
since the lead sheets when stored in this way tend to crack and thus allow radiation to
pass through them.

[Example of positioning arc equipment to avoid overhead scattered radiation of

occupationally exposed personnel.]
[Example of how lead aprons should be stored]

[Shooting position of the imaging technician.]