Introduction to C-arm technology

Learning outcomes

Identify all C-arm components and related equipment

Describe configuration and constraints of C-arm

Describe capabilities and clinical application of C-arm

for pre-, intra-, and postoperative imaging

Explain optimal positioning of patient, healthcare staff, and

equipment, while minimizing radiation exposure

Outline
What is a C-arm?
Image acquisition: collimation
Image intensifier
C-arm movement
Use of C-arm: pre-, intra-, and postoperatively
C-arm attitude:
Protective clothing
Technical contributions to radiation dose reduction
How much radiation is safe?

What is a C-arm?
Semi-circular C-shaped arm
X-ray source fixed to one end
Image intensifier fixed to other
end
Display screen shows live
image feed

Image intensifier requires

reduced amount of radiation to
produce image

Image courtesy of Siemens

Image acquisition: collimation

X-rays pass out of vacuum tube through a window sealed onto
vacuum envelope of x-ray tube
Size of window can be controlled (collimation)
The smaller the window, the sharper the x-ray and the smaller the
dose of radiation

Image intensifier
X-rays absorbed by image
intensifier, and thereby fluoresce
Image intensifier allows lowintensity x-rays to be amplified
Magnifies intensity produced in
output image
Result: less radiation emitted

C-arm movement

Horizontal

Mobile C-arms limited in

degree of movement

Swivel
Vertical

Rotation

C-arm orbital rotation

Orbital rotation around AP and lateral views ~132
C-arm cannot rotate more than the horizontal position
X-ray source on far side of body part being imaged

Orbital rotation

Image intensifier

X-ray tube

Image acquisition using the C-arm

High-quality images
Beam of x-ray travels perpendicular to limb/bone
Image intensifier as close to patient as possible

Surgical application of C-arm

Before surgical incision
Eg, confirm and grade degree of ligament damage
Intraoperatively
Eg, guide reduction and fixation
Postoperatively
Eg, check fixation

Surgical C-arm application: workflow example

Preoperative application: traction films

Bone overlap prevents planning

Traction films
facilitate planning

Preoperative application: screening for ligament

instability in ski thumb

Stress view of complete rupture of ulnar collateral ligament of

metacarpophalangeal joint of thumb (ski thumb)

Intraoperative application: dynamic hip screw

(DHS)

Intraoperative application: distal radial pinning

Do not place wrist

directly on x-ray source
during surgery

Intraarticular distal radius fracture

treated with multiple K-wires

Postoperative application: assessment of

reduction/fixation

Assessment of femoral nailing

(showing malrotation)
Assessment of Schatzker II
tibial plateau fracture fixation

Radiation: protective clothing

Gloves
6064% protection at 5258 KV
Eye protection
0.15 mm lead-equivalent goggles provide 70%
attenuation of radiographic beam
Thyroid collar
2.5-fold decrease in scattered radiation
Leaded apron
AP: 16-fold decrease in scattered radiation
Lateral: 4-fold decrease in scattered radiation

C-arm 'attitude' and technical contributions to

radiation dose reduction
Position x-ray tube under and close to
patient
Mark C-arm on floor and beam position
on patient
Use integrated lasers on x-ray tube and
image intensifier for positioning
Use pulse acquisition, avoid screening
Collimate when possible
Virtual patient anatomy selection:
correct dose for specified body area
Select dose rate in line with patient size
Maintain distance from patient

Reducing exposure to radiation

Minimize duration of exposure
Keep beam time to minimum
Trial screen after positioning patient
Rely on stored images when possible

Basic C-arm positioning

Place x-ray tube and
image intensifier to
minimize scatter
Patient as close to
image intensifier and
as far from x-ray tube
as possible

X-ray tube position

Staff exposed to
increased radiation

Staff exposed to reduced radiation

Absorption and scatter

For every 1000 photons
reaching patient
~20 reach image detector
~100200 scattered
remainder are absorbed by
patient (radiation dose)
Scattered dose is higher at
x-ray tube side

image intensifier

x-ray tube

Factors affecting patient doses

Intensifier diameter

12 (32 cm)

Relative patient entrance

dose mSv/h
Dose 100

9 (22 cm)

Dose 150

6 (16 cm)

Dose 200

4.5 (11 cm)

The smaller the image intensifier diameter,
the greater the patient entrance dose

Dose 300

Example of dose-rate around the C-arm

For staff, the further
from the patient the
lower the dose of
scattered radiation

How much radiation is safe?

20 mSv per year, average over
defined periods of 5 years
How do you know how much
radiation you have received?
Radiation dosimeter
(monitor)

Summary
Main components of C-arm: x-ray source, image intensifier, image
display screen
C-arm used to improve outcomes during pre-, intra, and postoperative
procedures
To reduce radiation exposure:
Position image intensifier close to patient
Surgeon and staff wear protective clothing and stand at safe
distance from C-arm
Pulse acquisition used as often as possible (avoid screening
unless necessary)