Orthopaedic surgeons work with radiation in some capacity almost every day. We would struggle to provide quality patient care if it were not for the many benefits that radiographic images provide us. But the more we are exposed to something, the less we tend to think about it. For example, how often do we discuss the risks of radiation exposure with our patients—especially those who are exposed to a large amount of it after an acute traumatic injury?
The article by Howard et al. in the August 7, 2019 issue of JBJS strongly suggests that polytrauma patients need to better understand the risks associated with radiation exposure as they progress through treatment of their injuries. The authors evaluated the cumulative 12-month postinjury radiation exposure received by almost 2,400 trauma patients who had an Injury Severity Score of 16+ upon admission. Those patients received a median radiation dose (not counting fluoroscopy) of 18.46 mSv, and their mean radiation exposure was 30.45 mSv. These median-versus-mean data indicate that a small subset of patients received substantially more radiation than others, and in fact, 4.8% of the cohort was exposed to ≥100 mSv of radiation. To put these amounts in context, the average human in the UK (where this study was performed) is exposed to about 2 mSv of background radiation per year, and there is good evidence suggesting that carcinogenesis risk increases with acute radiation doses exceeding 50 mSv.
Based on mathematical models (actual occurrences of cancer were not tracked), the authors conclude that for these patients, the median risk of fatal carcinogenesis as a result of medical radiation following injury was 3.4%. In other terms, 85 of these patients would be expected to develop cancer as a result of medical imaging—which struck me as a startling estimate.
So what are we to do? In a Commentary accompanying this study, David A. Rubin, MD, FACR offers some practical suggestions for reducing unnecessary radiation exposure. I personally feel that because the radiation associated with CT scans and radiographs can be, quite literally, life-saving for patients who have sustained traumatic injuries, increasing the chance that patients develop cancer later in life in order to save their life now is a good risk-benefit proposition. But the findings from this study should make us think twice about which imaging tests we order, and they should encourage us to help patients better understand the risks involved.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media