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Clinical Orthopaedics and Related Research

, Volume 467, Issue 1, pp 246–253 | Cite as

Digital Image Enhancement Improves Diagnosis of Nondisplaced Proximal Femur Fractures

  • Itamar Busheri Botser
  • Amir Herman
  • Ram Nathaniel
  • Dan Rappaport
  • Aharon Chechik
Original Article Research

Abstract

Today most emergency room radiographs are computerized, making digital image enhancement a natural advancement to improve fracture diagnosis. We compared the diagnosis of nondisplaced proximal femur fractures using four different image enhancement methods using standard DICOM (Digital Imaging and Communications in Medicine) after window-leveling optimization. Twenty-nine orthopaedic residents and specialists reviewed 28 pelvic images consisting of 25 occult proximal femur fractures and three images with no fracture, using four different image filters and the original DICOM image. For intertrochanteric fractures, the Retinex filter outperforms the other filters and the original image with a correct fracture type diagnosis rate of 50.6%. The Retinex filter also performs well for diagnosis of other fracture types. The Retinex filter had an interobserver agreement index of 53.5%, higher than the other filters. Sensitivity of fracture diagnosis increased to 85.2% when the Retinex filter was combined with the standard DICOM image. Correct fracture type diagnosis per minute for the Retinex filter was 1.43, outperforming the other filters. The Retinex filter may become a valuable tool in clinical settings for diagnosing fractures.

Level of Evidence: Level I, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Keywords

Intertrochanteric Fracture Visibility Score Proximal Femur Fracture DICOM Image Senior Physician 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

We thank Professor Shmuel Dekel, Dr. Niv Dreiangel, and Dr. Shay Tenenbaum for assistance with this study. IBB and AH contributed equally to this work.

References

  1. 1.
    Alba E, Youngberg R. Occult fractures of the femoral neck. Am J Emerg Med. 1992;10:64–68.PubMedCrossRefGoogle Scholar
  2. 2.
    Bogost GA, Lizerbram EK, Crues JV 3rd. MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology. 1995;197:263–267.PubMedGoogle Scholar
  3. 3.
    Braunstein EM, Capek P, Buckwalter K, Bland P, Meyer CR. Adaptive histogram equalization in digital radiography of destructive skeletal lesions. Radiology. 1988;166:883–885.PubMedGoogle Scholar
  4. 4.
    Chana R, Noorani A, Ashwood N, Chatterji U, Healy J, Baird P. The role of MRI in the diagnosis of proximal femoral fractures in the elderly. Injury. 2006;37:185–189.PubMedCrossRefGoogle Scholar
  5. 5.
    Clinkscales CM. MRI in the diagnosis of occult hip fractures in the elderly. Orthopedics. 1994;17:578.PubMedGoogle Scholar
  6. 6.
    Cohn M, Trefler M, Young TY. Enhancement and compression of digital chest radiographs. J Thorac Imaging. 1990;5:92–95.PubMedCrossRefGoogle Scholar
  7. 7.
    Egund N, Nilsson LT, Wingstrand H, Stromqvist B, Pettersson H. CT scans and lipohaemarthrosis in hip fractures. J Bone Joint Surg Br. 1990;72:379–382.PubMedGoogle Scholar
  8. 8.
    Eppley BL, Sadove AM. Computerized digital enhancement in craniofacial cephalometric radiography. J Oral Maxillofac Surg. 1991;49:1038–1043.PubMedCrossRefGoogle Scholar
  9. 9.
    Evans PD, Wilson C, Lyons K. Comparison of MRI with bone scanning for suspected hip fracture in elderly patients. J Bone Joint Surg Br. 1994;76:158–159.PubMedGoogle Scholar
  10. 10.
    Fairclough J, Colhoun E, Johnston D, Williams LA. Bone scanning for suspected hip fractures: a prospective study in elderly patients. J Bone Joint Surg Br. 1987;69:251–253.PubMedGoogle Scholar
  11. 11.
    Frihagen F, Nordsletten L, Tariq R, Madsen JE. MRI diagnosis of occult hip fractures. Acta Orthop. 2005;76:524–530.PubMedCrossRefGoogle Scholar
  12. 12.
    Gotfredsen E, Wenzel A, Grondahl HG. Observers’ use of image enhancement in assessing caries in radiographs taken by four intra-oral digital systems. Dentomaxillofac Radiol. 1996;25:34–38.PubMedGoogle Scholar
  13. 13.
    Guanche CA, Kozin SH, Levy AS, Brody LA. The use of MRI in the diagnosis of occult hip fractures in the elderly: a preliminary review. Orthopedics. 1994;17:327–330.PubMedGoogle Scholar
  14. 14.
    Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. Radiology. 1990;174:509–515.PubMedGoogle Scholar
  15. 15.
    Hsu J, ed. Multiple Comparison,Theory and Methods. London, England: Chapman & Hall; 1996.Google Scholar
  16. 16.
    Hughes SS, Voit G, Kates SL. The role of computerized tomography in the diagnosis of an occult femoral neck fracture associated with an ipsilateral femoral shaft fracture: case report. J Trauma. 1991;31:296–298.PubMedCrossRefGoogle Scholar
  17. 17.
    Khocht A. Computerized image capture, storage, retrieval, and enhancement in digital radiography. Pract Proced Aesthet Dent. 2004;16:477–478.PubMedGoogle Scholar
  18. 18.
    Kim JH, Im JG, Han MC, Min BG, Lee CW. Improved visualization of stimulated nodules by adaptive enhancement of digital chest radiography. Acad Radiol. 1994;1:93–99.PubMedCrossRefGoogle Scholar
  19. 19.
    Laurin S, Jonsson K, Jonsson R. [Low frequency of missed or invisible hip fracture in X-ray examination: the rule-of-2-a simple method for quality assessment][in Swedish]. Lakartidningen. 2004;101:2423–2425.PubMedGoogle Scholar
  20. 20.
    Lim KBL, Eng AKH, Chng SM, Tan AGS, Thoo FL, Low CO. Limited magnetic resonance imaging (MRI) and the occult hip fracture. Ann Acad Med Singapore. 2002;31:607–610.PubMedGoogle Scholar
  21. 21.
    Lindberg EJ, Macias D, Gipe BT. Clinically occult presentation of comminuted intertrochanteric hip fractures. Ann Emerg Med. 1992;21:1511–1514.PubMedCrossRefGoogle Scholar
  22. 22.
    Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R. Early diagnosis of occult hip fractures MRI versus CT scan. Injury. 2005;36:788–792.PubMedCrossRefGoogle Scholar
  23. 23.
    Meylan L, Susstrunk, S. High dynamic range image rendering using a Retinex-based adaptive filter. IEEE Trans Image Process. 2006;15:2820–2830.Google Scholar
  24. 24.
    Moore CJ. Measurements from digital scanned projection radiographs: couch detail and detector artefact removal by simple image enhancement. Br J Radiol. 1985;58:756–759.PubMedGoogle Scholar
  25. 25.
    Oestmann JW, Greene R, Rubens JR, Pile-Spellman E, Hall D, Robertson C, Llewellyn HJ, McCarthy KA, Potsaid M, White G. High frequency edge enhancement in the detection of fine pulmonary lines: parity between storage phosphor digital images and conventional chest radiography. Invest Radiol. 1989;24:643–646.PubMedCrossRefGoogle Scholar
  26. 26.
    Pandey R, McNally E, Ali A, Bulstrode C. The role of MRI in the diagnosis of occult hip fractures. Injury. 1998;29:61–63.PubMedCrossRefGoogle Scholar
  27. 27.
    Parker M, Johansen A. Hip fracture. BMJ. 2006;333:27–30.PubMedCrossRefGoogle Scholar
  28. 28.
    Parker MJ. Missed hip fractures. Arch Emerg Med. 1992;9:23–27.PubMedGoogle Scholar
  29. 29.
    Pathak G, Parker MJ, Pryor GA. Delayed diagnosis of femoral neck fractures. Injury. 1997;28:299–301.PubMedCrossRefGoogle Scholar
  30. 30.
    Perron AD, Miller MD, Brady WJ. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med. 2002;20:234–237.PubMedCrossRefGoogle Scholar
  31. 31.
    Pool FJ, Crabbe JP. Occult femoral neck fractures in the elderly: optimisation of investigation. N Z Med J. 1996;109:235–237.PubMedGoogle Scholar
  32. 32.
    Powlis WD, Brikman I, Seshadri SB, Bloch P. Portal radiographs: digital enhancement of contrast. Radiology. 1988;169:839–841.PubMedGoogle Scholar
  33. 33.
    R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2007.Google Scholar
  34. 34.
    Reddy MS, Bruch JM, Jeffcoat MK, Williams RC. Contrast enhancement as an aid to interpretation in digital subtraction radiography. Oral Surg Oral Med Oral Pathol. 1991;71:763–769.PubMedCrossRefGoogle Scholar
  35. 35.
    Rehm K, Seeley GW, Dallas WJ, Ovitt TW, Seeger JF. Design and testing of artifact-suppressed adaptive histogram equalization: a contrast-enhancement technique for display of digital chest radiographs. J Thorac Imaging. 1990;5:85–91.PubMedCrossRefGoogle Scholar
  36. 36.
    Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip: magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg Am. 1993;75:395–401.PubMedGoogle Scholar
  37. 37.
    Scholz A, Langer M, Zwicker C, Felix R. Picture quality of a digital urogram using image enhancement radiography [in German]. Digitale Bilddiagn. 1989;9:31–35.PubMedGoogle Scholar
  38. 38.
    Schultze J. Occult fracture of the femoral neck fractures of the proximal femur [in German]. Nuklearmedizin. 1998;37:80–82.PubMedGoogle Scholar
  39. 39.
    Shrout MK, Russell CM, Potter BJ, Powell BJ, Hildebolt CF. Digital enhancement of radiographs: can it improve caries diagnosis? J Am Dent Assoc. 1996;127:469–473.PubMedGoogle Scholar
  40. 40.
    Stahl M, Aach T, Dippel S. Digital radiography enhancement by nonlinear multiscale processing. Med Phys. 2000;27:56–65.PubMedCrossRefGoogle Scholar
  41. 41.
    Verbeeten KM, Hermann KL, Hasselqvist M, Lausten GS, Joergensen P, Jensen CM, Thomsen HS. The advantages of MRI in the detection of occult hip fractures. Eur Radiol. 2005;15:165–169.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons 2008

Authors and Affiliations

  • Itamar Busheri Botser
    • 1
  • Amir Herman
    • 1
  • Ram Nathaniel
    • 2
  • Dan Rappaport
    • 2
  • Aharon Chechik
    • 1
  1. 1.Department of Orthopedic SurgeryChaim Sheba Medical CenterRamat GanIsrael
  2. 2.Surgix Orthopedic Solutions Ltd.Tel-AvivIsrael

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