The Positioning Of Gonad Protection Health And Social Care Essay
To justify imaging of a patient there are some points to consider and they include the value of the results being greater than the risk of the examination. Haller, Slovis, and Joshi, (2005). According to ICRP Publication 34 (1983), it is more difficult to shield ovaries in females than male gonads. A few factors like size and shape has to be considered. Experience comes into use especially when imaging children. Too large a shield may result in the radiography being repeated if it obscures important anatomical regions and too small a shield will defeat the purpose of shielding. There is a combination of technique and positioning of the shield that has to be explored and improved if full diagnostic advantage is to be implemented and practised.
The intentions of this study aims at continuous improvement following an audit carried out in 2006 on use and accuracy in positioning of gonad protection for paediatric pelvic radiographs. The study was carried out on the same local hospital, (McCarty, Waugh, McCallum, Montgomery, and Aszkenasy, 2001). An audit is the tool used to identify and monitor technique and finding ways to improve.
Introduction
The aim of this project is to establish the accuracy in positioning of gonad protection when imaging pelvis of children. The researcher is also looking into repeats due to movement or incorrect positioning of the gonad shield. This is to focus on the radiographs taken with gonad protection and had to be repeated because of the gonad protection obscuring the area of interest, (Hardyand Boynes, 2003).
It has been and is still a big concern that hip and pelvis radiographs contribute to the radiation exposure to the gonads especially on paediatrics. There are devices available to protect the gonads during imaging. There is a lot of research done in the necessity and benefits of gonad shielding and it is conclusive that it is essential to shield the gonads. This study is designed to assess the accuracy of placement of the shields for hip and pelvis radiographs in children under the age of sixteen, (Fawcett and Barter, 2009).
The data is collected through an audit carried out by the researcher from a local hospital. This study also aims at looking at the number of radiographs taken with gonad protection versus those taken without. This is to rationalise the need to improve in technique or design of the gonad protection tools. This might also constitute the need for training on positioning of the gonad shielding. This can only be achieved by looking at a set of radiographs for each case and establish the accuracy in technique and the use of gonad protection, (Fawcett and Barter, 2009).
The study is specific to a local hospital. A hundred paediatric, anteroposterior (AP) pelvis and frog lateral radiographs are reviewed from the local hospital. This study also includes the repeated radiographs due to incorrect positioning of the gonad shielding. The parameters are set using the landmarks of orthopaedic visualisation shown on the diagram below.
The image has been retrieved from; Fawcett and Barter, (2009).
The departmental protocols of the hospital were the study has been carried out recommends that gonad shielding is used on all follow-up radiographs of paediatrics, (Fawcett and Barter, 2009). It also follows that when a patient has been exposed to ionisation radiation even if the image is not adequate but has minimal information it should not be rejected. It can be repeated and both images send through to PACS.
Literature Review
Gonads are deemed the body’s most radiosensitive organ according to the International Commission of Radiation Protection (ICRP), (2007). Radiation exposure to the gonads has a potential damage to hereditary and malignant changes estimated for the first two generations. The genetic effect has no threshold dose and they are therefore stochastic. Organs and tissues of the reproductive system are extremely sensitive to radiation. The NRPB recommends the correct use of gonad protection for patients of the bearing age or below. Departmental protocols should also include the correct use and when to apply gonad shielding to reduce dose without loss of radiographic information, (Doolan, Brennan, Rainford and Healy, 2004).
It is understood that imaging of children posses particular challenges. The younger the child the more radiosensitive the bone marrow and the greater the potential harm. Digital radiography allows greater reduction in radiation dose. Other factors like shorter exposure times and good collimation does contribute to the reduction. Because of the sensitivity of the reproductive organs and tissues in people of child bearing age and younger it is paramount to protect the gonads, (Benson, Fixsen and Macnicol, 2009).
Hohl, Mahnken, Klotz, Das, Stargardt, Mühlenbruch, Schmidt, Günther and Wildberger, (2005) carried out a study with the objective to quantify the effects of a standard gonad shield on the testicular radiation exposure due to scatter during routine abdominopelvic MDCT. They concluded that shielding male gonads reduces the testicular radiation dose during abdominopelvic MDCT significantly and can be recommended for routine use. This is an emphasis on the importance of shielding the gonads.
Hardyand Boynes, (2003), also stresses the use of gonad protection for all paediatrics. This reduction in dose is only possible if the lead protection is placed at the field edge. If it is placed further away then it is less effective to not effective at all “and at a distance of 4cm or more it is ineffective as a radiation protection measure”.
Simple dose reduction methods that do not impair diagnostic image quality should be considered first. (Dauer, Casciotta, Erdi and Rothenburg, 2007).
According to Berry, (2004), tight collimation is regarded as the best gonadal protection in excluding the gonads from direct exposure. Where it is not possible gonadal shielding should be applied. The gonads should be protected when they are directly in the x-ray beam or within 5cm of it. Gonad shielding should be applied at all instances unless it will exclude or degrades important diagnostic information. The other reason for gonadal shield not being used could be due to the unavailability of the shield devices in the x-ray rooms as Doolan, Brennan, Rainford, and Healy, (2004) suggested.
Effective protection of the ovaries is more difficult as they generally lie within the pelvis. For ovaries, fixation of the shadowing material at the collimator should be considered over contact shielding which can be easily displaced during the examination where possible. Displacement of the contact shielding can possibly shadow the hip joints causing the need for retakes. This might yield the need for re-design of the gonad protection shields, (Berry, 2004). Bushong (2001) also collaborate the fact that ovaries present a challenge when it comes to positioning whereas leaded gonadal shielding in the shape of testicles presents less difficulties.
For the purpose of this study only the method of using gonad shields is considered.
Anteroposterior (AP) radiography of the pelvis is the primary imaging assessment of the paediatric hips. Initial trauma films should be taken without gonad protection, as this may obscure fractures. If the child is being followed up and the pathology is known, lead protection should be used. The protection should be positioned so as not to obscure the pathology, (Johnson and Bache, 2007).
Absence or incorrect positioning of the gonadal shields may still cause direct gonadal damage and mutation. The guidelines in the hospital were the study was carried out exclude the first pelvic radiography of a trauma patient on those within child bearing age and all children under the age of sixteen. The protection is considered on all subsequent examination after the first anteroposterior projection of the pelvis or hips, (Gul, Zafar and Maffulli, 2005).
According to Cameron, Jelinek, Everitt and Browne, (2006), displaced fractures are common and highly traumatic even for children. Rapid attention is required including imaging to minimise the effects of the trauma. Certain missed fractures have a highly propensity for serious long term functional morbidity and must be actively sought or excluded. These include slipped upper femoral epiphysis. This validates and support why not to use the gonad shield on the initial x-ray.
Children with chronic hip conditions such as Perthes disease and developmental dysplasia of the hip have repeated pelvic x-rays during the course of their disease. It is vital to minimise radiation dose and protect the gonads in the series of radiographs. The correct use of gonad shielding can reduce the accumulation of dose during childhood which can lead to the risk of radiation induced cancers and genetic damage, (Waugh, McCallum, McCarty, Montgomery and Aszkenasy, 2001).
Figure 1 below shows the ideal positioning of a gonad shield in a female patient and figure 2 show the ideal positioning in a male patient.
The images has been retrieved from; Fawcett, S. L. and Barter, S. J., (2009). The use of gonad shielding in paediatric hip and pelvis radiographs. The British Journal of Radiology, 82 (1), 363-370.
Once an entire population of spermatogonial cells in the testis or primordial follicles in the ovary have been lost they cannot be replaced naturally. Damage induced by radiation dose depends on the age and gender. In boys, future sperm production is susceptible to damage at very low doses of radiation; this is according to (Balen and Creghton, 2004).
Cook, (2001) says that the new Ionising Radiation (Medical Exposure) Regulations, recognises children as a special case in imaging. Staffs that examine children should be experienced and trained in the care and imaging of paediatrics. Radiology departments should have agreed protocols and diagnostic pathways. They should also have standardised techniques and comparable diagnostic quality of images and doses published in reference to children and their ages. Good radiographic technique is a vital factor in improving image quality without compromise of increased dose.
Infants and children present a special challenge for radiographers. Infants and small children are unable to cooperate and follow verbal directions. It is the radiographer’s responsibility to minimise movement and discomfort and safeguarding the child’s safety, Linder, and Schiska, (2007). Immobilization is critical to the success of any radiography as Carlton and Adler, (2006) wrote. Movement blurs the edges of closely spaced objects and in paediatric patients the resultant is repeated radiographs, Bushong, (2001)
A retrospective study was carried out in 2003 – 2004 to determine whether gonadal shields effectively protected the gonads. On almost 50% the gonads were protected and completely omitted in about 29% and in about 22% the gonad shields did not adequately protect the gonads, (Gul, Zafar and Maffulli, 2005).
A similar study was carried on another hospital in 1996 and presents the projected results of this study. The objective of the study carried out by (McCarty, Waugh, McCallum, Montgomery, and Aszkenasy, (2001), was a retrospective audit of 206 paediatric pelvic radiographs undertaken in 1996. Each radiograph was assessed for the presence of a gonad shield, appropriateness of the devise and its position. They came to the conclusion that an audit was an effective tool in gaining the resources needed to improve technique and reduce radiation exposure in children. They recommended training for radiographers in order to improve technique.
Another study was carried out with the objective to determine whether gonad shields were correctly positioned on the pelvic radiographs of children with slipped capital femoral epiphysis and this goes back to the date of 1998. The study was set in three teaching hospitals in North West of England. They came to the conclusion that gonad shields were not protecting the gonads in a large percentage. This low percentage was as a result that the gonad shields have been inadequately placed (Kenny, and Hil, 1992).
Methodology
Method of data collection is using existing information on a computer database from hospital Z. This will be achieved by designing a compilation sheet which matches the data source but only taking account of the required parameters. (Appendix checklist) Only examinations with more than one image were considered due to the departmental protocols for excluding the initial radiograph in trauma cases. The examinations with a single conventional radiography (CR) image and referred to other modalities for imaging were also considered, International Development Research Centre (IDRC), 2003. The researcher will be viewing and reading a database of radiographs using stipulated parameters from an allocated Accident and Emergency workstation or reporting room workstation. (Appendix checklist). Because of the method of data collection a large sample is required for analysis, in order to be representative and conclusive.
There is enough evidence that radiation from x-rays causes direct gonadal damage and mutation. This audit considered 100 radiographs of paediatrics of ages zero to sixteen, taken over a period of two years. The parameters set to include paediatrics and the hundred radiographs were chosen at random, (Sikand, Stinchcombe, and Livesley, 2003).
For analysis the researcher is looking at quantitative analysis with descriptive statistics using the chi-square test. This includes the use of database software SPSS for Windows. The researcher also intend to look at the archive for repeats but there is an awareness that rejected radiographs are not send to PACS but can be viewed on the processing workstation for a limited period of time. The researcher is also relying on the fact that not all images are rejected even if they carry minimal information as stated in the departmental local rules. Below are the combinations and comparisons of data considered?
Using shielding versus positioning
Using shielding versus gender
Used shielding versus size
Used shielding versus repeats
Using shielding versus age
Gender versus repeats
Gender versus size
Positioning versus gender
A hundred radiographs chosen at random from January 2008 to January 2010 were determined. A recording of radiographs of children under the age of sixteen where gonad shielding was used and where it was not used was recorded. If the shield was present a record was also made to whether the gonads were effectively protected. In boys, the position of the gonads was considered to be within the scrotal sac, which is visible on an anteroposterior plain pelvic radiograph, (Kenny and Hill, 1992). The female gonads were considered to rest adjacent to ischial spine above the pubic arch, and are also visible on plain pelvic radiographs, (Gul, Zafar and Maffulli, 2005).
Ethical implications were considered in this study and an application was forwarded and approved by the ethical committee at the University of Hertfordshire. (Appendix HEPEC). There are no potential risks or hazards anticipated due to the method of data collection. The study is in a form of an audit using a computer database and no patient information is required except only at the time of data collection of which only the researcher is invloved. A checklist with defined parameters was used. (Appendix checklist)
According to the study carried out by Sikand, Stinchcombe and Livesley, (2003) on whether the national guidelines issued by all hospital radiology departments were being followed showed that, the decision on using the gonad protection shield should be made with the understanding of the expected doses to the gonads and an indication for why the x-ray is being done. The conclusion was the guidelines should be adhered to as far as possible and an effort always made to decrease radiation exposure. All clinicians, radiologist and radiographers have a duty and responsibility for protecting patients. Regular audits are essential to ensure adherence to the guidelines and use of gonad protection shields, (McCallum, Montgomery, and Aszkenasy, 2001)
Results
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Used shielding * Correct Positioning
100
87.0%
15
13.0%
115
100.0%
Used shielding * Correct Positioning Cross-tabulation
Count
Correct Positioning
Total
No
Yes
N/A
Used shielding
No
34
34
Yes
16
50
66
Total
16
50
34
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Pearson Chi-Square
100.000a
2
.000
Likelihood Ratio
128.207
2
.000
Linear-by-Linear Association
73.337
1
.000
N of Valid Cases
100
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 5.44.
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Used shielding * Sex of patient
100
87.0%
15
13.0%
115
100.0%
Used shielding * Sex of patient Cross-tabulation
Count
Sex of patient
Total
Female
Male
Used shielding
No
26
8
34
Yes
26
40
66
Total
52
48
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Exact Sig. (2-sided)
Exact Sig. (1-sided)
Pearson Chi-Square
12.359a
1
.000
Continuity Correctionb
10.918
1
.001
Likelihood Ratio
12.866
1
.000
Fisher’s Exact Test
.001
.000
Linear-by-Linear Association
12.235
1
.000
N of Valid Cases
100
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 16.32.
b. Computed only for a 2×2 table
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Used shielding * Correct size
100
87.0%
15
13.0%
115
100.0%
Used shielding * Correct size Cross-tabulation
Count
Correct size
Total
No
Yes
N/A
Used shielding
No
34
34
Yes
8
58
66
Total
8
58
34
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Pearson Chi-Square
100.000a
2
.000
Likelihood Ratio
128.207
2
.000
Linear-by-Linear Association
79.250
1
.000
N of Valid Cases
100
a. 1 cells (16.7%) have expected count less than 5. The minimum expected count is 2.72.
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Used shielding * Repeats
100
87.0%
15
13.0%
115
100.0%
Used shielding * Repeats Cross-tabulation
Count
Repeats
Total
No
Yes
Used shielding
No
34
34
Yes
51
15
66
Total
85
15
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Exact Sig. (2-sided)
Exact Sig. (1-sided)
Pearson Chi-Square
9.091a
1
.003
Continuity Correctionb
7.396
1
.007
Likelihood Ratio
13.795
1
.000
Fisher’s Exact Test
.002
.001
Linear-by-Linear Association
9.000
1
.003
N of Valid Cases
100
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 5.10.
b. Computed only for a 2×2 table
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Used shielding * Age group
100
87.0%
15
13.0%
115
100.0%
Used shielding * Age group Cross-tabulation
Count
Age group
Total
0yrs – 5yrs
6yrs – 10yrs
11yrs – 16yrs
Used shielding
No
8
17
9
34
Yes
12
33
21
66
Total
20
50
30
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Pearson Chi-Square
.535a
2
.765
Likelihood Ratio
.531
2
.767
Linear-by-Linear Association
.519
1
.471
N of Valid Cases
100
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 6.80.
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Sex of patient * Repeats
100
87.0%
15
13.0%
115
100.0%
Sex of patient * Repeats Cross-tabulation
Count
Repeats
Total
No
Yes
Sex of patient
Female
45
7
52
Male
40
8
48
Total
85
15
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Exact Sig. (2-sided)
Exact Sig. (1-sided)
Pearson Chi-Square
.201a
1
.654
Continuity Correctionb
.028
1
.866
Likelihood Ratio
.201
1
.654
Fisher’s Exact Test
.781
.432
Linear-by-Linear Association
.199
1
.655
N of Valid Cases
100
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 7.20.
b. Computed only for a 2×2 table
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Sex of patient * Correct size
100
87.0%
15
13.0%
115
100.0%
Sex of patient * Correct size Cross-tabulation
Count
Correct size
Total
No
Yes
N/A
Sex of patient
Female
4
22
26
52
Male
4
36
8
48
Total
8
58
34
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Pearson Chi-Square
12.769a
2
.002
Likelihood Ratio
13.286
2
.001
Linear-by-Linear Association
8.094
1
.004
N of Valid Cases
100
a. 2 cells (33.3%) have expected count less than 5. The minimum expected count is 3.84.
Case Processing Summary
Cases
Valid
Missing
Total
N
Percent
N
Percent
N
Percent
Correct Positioning * Sex of patient
100
100.0%
.0%
100
100.0%
Correct Positioning * Sex of patient Cross tabulation
Count
Sex of patient
Total
Female
Male
Correct Positioning
No
10
6
16
Yes
16
34
50
N/A
26
8
34
Total
52
48
100
Chi-Square Tests
Value
df
Asymp. Sig. (2-sided)
Pearson Chi-Square
16.876a
2
.000
Likelihood Ratio
17.512
2
.000
Linear-by-Linear Association
3.740
1
.053
N of Valid Cases
100
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 7.68.
Summary of Results
The results show that out of the hundred radiographs in the study, in 66 cases the gonad shielding was used against 34 cases where shielding was not applied. The 34 cases of which the gonad shielding was not used fall under several reasons as to why they were not used and that include that maybe only a single radiography were taken. Being a trauma case or an emergency the local protocols justifies not using shielding on initial radiographs. In some instances after the initial radiograph the patient was referred to other modalities like computed tomography (CT) or ultrasound (US).
The above results on used shielding versus positioning cross tabulation indicate that out of the 66 cases were shielding was used 50 cases (76%) had correct positioning and on 16 cases (24%) there was incorrect positioning. The incorrect positioning was determined by either the gonad shielding being too low or too high. On rare cases they were on one side of the pelvis of which there is an assumption that it could be due to movement other than incorrect placement of the gonad shield.
On the cross tabulation of used shielding versus gender the results indicate that out of the 34 cases were gonad shielding was not used 26 of the cases (76%) were females and only 8 cases (24%) were male. On the 66 cases were gonad shielding was used a great number appear to be male 40 (61%) and 26 cases (39%) were female. Out of the total number of cases on the study (100) 52% are females and 48% males.
In terms of used shielding versus size tabulation, there is not much of a significant problem as indicated in the results table. Incorrect sizes where used on 8 cases (12%) and 58 cases (88%) had the correct size used.
On used shielding versus repeats tabulation, it is showing that out of the 66 cases where shielding of the gonads was used only 15 cases (23%) were repeated for one reason or the other. 51 of the cases (77%) were not repeated. On the repeated cases there is no suggestive reason as to why they were repeated. The data for the repeats are retrieved from an accident and emergency and they might not be a true representation as all repeats are not stored onto PACS and the reason for repeats can be anything from technique to technical faulty.
The tabulation of used shielding versus age group indicate that between the 0 -5 years age only 12 cases (19%) , 33 cases (50%) recorded between the age of 6 -10 years and 21cases (31%) and between the ages 11 – 16 years. The greater number of cases is found between the ages 6 – 10 were gonad shielding was used.
Gender versus repeats tabulation shows 45 cases of no repeats (87%) and 7 cases (13%) of females had been repeated. On male side 40 cases (83%) were not repeated and 8 cases (17%) of them were repeated. On gender versus size tabulation 4 cases (8%) of female and 4 cases (8%) of male the incorrect size shielding was used.
On positioning versus gender cross tabulation the results reads that 10 cases (63%) of females, the positioning was inaccurate and 6 cases (37%) of male the positioning was inaccurate out of the total of 16 cases.
Critical Discussion and Analysis
The work presented in this article is a small study resulting from an undergraduate project. It describes the situation in a local hospital and does not attempt to extrapolate the data gathered from this hospital to the wider situations. As such its scope is small.
The results indicate that the children are receiving avoidable excess gonadal irradiation due to the inadequate positioning or complete omission of gonad shields. Putting this into perspective we are focusing on the 66 cases were gonad shielding was used. The fact that out of the 100 cases only 66% had the gonad protection leaves us wondering whether the protocols are being adhered to or the 34% were gonad protection was not used falls under the initial radiographs. Without the definite reason why they were omitted this study does not answer the question of whether there is an increase in the use of shielding on paediatrics compared to previous studies. This study is limited to accuracy in position of the gonad shield and only extends to focus on repeats and size.
Comparing the results of a previous audit done at the same hospital there is a significant increase in accuracy of positioning of both female and male patients. This is an indication that the standards set for improvement in the last audit took effect and can be revised and new standards of improvement implemented for even better results. The last audit was split into two rounds and there was an increase in accuracy from 27% in round one to 44% in round two and now the results show an increase of up to 76%.
The inadequate positioning of gonad shields is more common in female patients than male patients. This could be due to the difficulty in positioning of the shield in relation to surface landmarks. There is a significant difference between female and male position of the gonad shielding as the results show 63% inaccurate positioning of the shield in females compared to 33% in males. It also reflects on the accurate positioning as 24% adequate positioning was recorded in females compared to the 74% in males. This brings the question on the design of female shielding. There is not much research done in finding ways to improve it compared to the testes shielding in male patients. It could be argued that maybe there is a need for a redesign of the gonad shield which is much easier to position accurately and reliably especially for female patients or training to radiographers.
The results are similar to the other studies carried out. The gonadal shields were absent in 34% of the cases and 23% of repeats and 24% of inaccurate positioning. The actual radiation dose to the gonads or whether the patients had additional radiological investigation such as CT or fluoroscopy is beyond the scope of this study. There is a possibility that these children received even higher exposure to ionising radiation due to repeats and incorrect positioning. These figures indicate a huge problem knowing the issues that can be caused by the unnecessary exposure to radiation of the gonads. Looking at the images below they all show the need for repeat all due to incorrect positioning of the lead shield in female patients;
Figure 1. Bony anatomy is obscured by the gonad shield. Figure 3. Gonad shield is obscuring the sacroiliac joints
The images have been retrieved from: Doolan, A., Brennan, P. C., Rainford, L. A. and Healy, J., (2004). Gonad protection for the anteroposterior projection of the pelvis in diagnostic radiography in Dublin hospitals. The Society and College of Radiographers, Elsevier, 10 (1), 15-21.
The results on repeats still show a major problem that need addressing. If incorrect positioning is resulting in repeating the radiography due to obscuring of bony anatomy or sacroiliac joints as indicated in figure 1 and figure 2 respectively then it defeats the purpose of shielding in the first place. The patient will end up receiving double the dose without shielding the gonads as intended.
The study considered the need for strict adherence to guidelines to be monitored to achieve the required level of protection from unnecessary radiation. It is the cumulative effect of multiple x-rays that cause problems. It appears that the concept of omitting gonad protection on the initial radiograph is a reflection of the difficulties posed for accurate application in the first place. Omission is preferable to the unintentional obscuring of the very structures that need to be imaged. And this has the consequent for a repeat exposure. But again this study does not guarantee that measure the number of radiographs that may have been rejected and repeated without the lead gonadal shield due to inaccurate positioning. Re-audit has been shown to improve the effective use of shielding, with the accuracy reaching 44% after round 2 and as high as 76% on this study.
Figure 2. Gonad shield is too small.
Figure 4. Gonad shield not protecting the gonads completely and the left ischial tuberosity is obscured
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