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.
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