Radiographs are in integral part of fracture evaluation and treatment. Although plain film images are the "gold-standard" in fracture evaluation, the plain film cannot be electronically transmitted, projected or stored. Digital imaging is a definite trend in radiograph science, and the orthopaedic trauma surgeon will need to exploit the advantages of this technology.

The purpose of this study is to analyze the different methods of digital radiograph imaging and to determine which is the most advantageous. There are three different points that digital radiographic images must address:

Of the different modalities that may be used to obtain digital images, the following devices were selected for this project:

The characteristics of the specific devices selected for this study are listed below:

Both objective and subjective data will be collected to compare the different devices. The fracture selected as the subject of this study will need to have certain characteristics:

1. Image quality — the fracture will need to be one that requires a high quality image in order to select a specific treatment.
2. Importance — the fracture will need to be of sufficient importance that accurate determination of the fracture morphology is of interest to orthopaedic surgeons.

Different fractures may meet these qualifications. Displaced Winquist-Hansen I femur fractures are easily diagnosed, and these injuries would not present an image that would adequately assess the quality of the digital images. These are different fractures that may be appropriate for this study:

After selection of the fracture to be studied, careful selection of six such injures would be undertaken. These images would need to be of excellent quality, and the injury would need to be "subtle" so that the quality of the images would be truly tested. Four uninjured (control) radiograph sets would also be obtained comprising ten radiograph sets to be studies. These sets would be identified as patient "A" through patient "J". This volume of images (ten patients, twenty or thirty films) is reasonable so that there are enough images for the study, but there are not so many images that the evaluators would tire of the project.

The four different devices would image the ten sets of radiographs, and the time required to obtain and download the images into the computer would be recorded. The images would then be randomized into four groups. Each group would contain ten image sets (e.g. AP and lateral). Patient "A" through "J" would only have one set of images in each group, and each group would be equally comprised of the different imaging systems (digital cameras, scanner, PACS). Therefore, there would be four groups consisting of ten images sets randomized with respect to the different devices and no individual injury being represented more than once per set.

The images would be displayed on the same computer monitor for all evaluators. This is an important point in that the quality of the monitor would definitely affect the image quality and be an unnecessary covariable. The monitor would be of high quality, but common enough that it could be available to the average orthopaedic surgeon.

Each of the evaluators would be asked to judge the image sets according to several characteristics. Most studies of this type have asked, "Is there an injury?", and the evaluators would respond to this question with one of the five answers listed below:

1. Definitely normal structure.
2. Possibly normal structure.
3. Unable to assess.
4. Possibly abnormal structure.
5. Definitely abnormal structure.

In this study, the evaluators would also be asked the following questions for each image set:

"What type of injury (if any) is displayed on this image set?"

"Is this an operative injury?"

Please grade the quality of this image (1 — terrible, 10 — excellent)

"Is this image suitable for projection at grand rounds or an orthopaedic meeting?"

Eight separate evaluators would be chosen for this study. The evaluators would be from the following groups:

1. Board certified orthopaedic trauma surgeons — Drs. Johnson, McAndrew and Edwards.
2. Orthopaedic trauma fellow — Dr. Rudolph.
3. Orthopaedic resident, senior level — two to be selected.
4. Orthopaedic resident, junior level — two to be selected.

Each evaluator would view the ten image sets in first image group at one setting. The evaluator would be allowed no more than one minute to evaluate each image set. The evaluator would answer the questions listed above as decisively as possible for each image set. For each evaluator, there will be a three-week delay between evaluations of each of the image groups. After all four groups have been evaluated, each evaluator will view the original radiographs of the ten patients and answer the same questions.

After the eight evaluators have reviewed the four image groups and the original film group, the results will be tabulated and analyzed. The quality judgements of the different imaging devices will than be compared to their price and ease of digitizing the images.

This study should enable the reader to compare the level of quality of the digitized image to the cost and ease of use of each system. An absolute answer to the question "How much quality is necessary for digitized images" is probably impossible to determine since images are used for many different purposes. This study should answer the question, "Which method(s) of digitizing radiographs are appropriate for imaging radiographs depicting (the injury that we select)?".

The eight evaluators would need to be willing and available to sit on five different occasions to review the image groups. Six high-quality, fracture radiograph sets would need to be obtained from the archives in the department of radiology, and four uninjured radiograph sets would need to be obtained. (I would volunteer to be radiographed for one set of these). A high quality computer and monitor would need to be available.

This is my proposal for evaluation of the different modalities available for digitizing radiographs. This is the sequence of events:

1. Approval of proposal and selection of fracture type (odontoid, femoral neck etc.) to study.
2. Coordination with radiology for specifics of PACS system.
3. Acquire digital camera and scanner.
4. Obtain suitable films for study.
5. Imaging of the films by the different devices.
6. Troubleshooting and adjustment as necessary.
7. Selection and education of the reviewers.
8. Begin study.