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AI-based X-ray fracture analysis of the distal radius: accuracy between representative classification, detection and segmentation deep learning models for clinical practice

Objectives: To aid in selecting the optimal artificial intelligence (AI) solution for clinical application, we directly compared performances of selected representative custom-trained or commercial classification, detection and segmentation models for fracture detection on musculoskeletal radiographs of the distal radius by aligning their outputs.

Design and setting: This single-centre retrospective study was conducted on a random subset of emergency department radiographs from 2008 to 2018 of the distal radius in Germany.

Materials and methods: An image set was created to be compatible with training and testing classification and segmentation models by annotating examinations for fractures and overlaying fracture masks, if applicable. Representative classification and segmentation models were trained on 80% of the data. After output binarisation, their derived fracture detection performances as well as that of a standard commercially available solution were compared on the remaining X-rays (20%) using mainly accuracy and area under the receiver operating characteristic (AUROC).

Results: A total of 2856 examinations with 712 (24.9%) fractures were included in the analysis. Accuracies reached up to 0.97 for the classification model, 0.94 for the segmentation model and 0.95 for BoneView. Cohen's kappa was at least 0.80 in pairwise comparisons, while Fleiss' kappa was 0.83 for all models. Fracture predictions were visualised with all three methods at different levels of detail, ranking from downsampled image region for classification over bounding box for detection to single pixel-level delineation for segmentation.

Conclusions: All three investigated approaches reached high performances for the detection of distal radius fractures with simple preprocessing and postprocessing protocols on the custom-trained models. Despite their underlying structural differences, the selection of one's fracture analysis AI tool in the frame of this study reduces to the desired flavor of automation: automated classification, AI-assisted manual fracture reading, or minimized false negatives.


BoneView, our first clinical AI application, has become a global bone trauma X-ray interpretation standard, recognized for its scientific excellence. It pinpoints fractures, effusions, dislocations, and bone lesions efficiently. Recognized for its scientific rigor with publications in top-tier peer-reviewed journals, its clinical study won the prestigious 2022 Alexander Margulis Award for scientific excellence.

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