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Automatic Recognition of Pertrochanteric Bone Fractures in Femur

using Level Sets*

Ling Wang, Hong Cheng, Hai Lan, Yingjie Zheng, Kainan Li

Abstract Femur fracture is one of the common diseases

in the elderly. In this paper, an automatic and efficient
classification method of femoral pertrochanteric fractures is
proposed based on image segmentation techniques. The types
of femoral pertrochanteric fracture are defined firstly according !"#!$%"&&'()
to the difference of fracture parts. To reduce the computational
complexity, only four directions images are used in each
3D femur, i.e. the anterior, the anterolateral, the posterior *+,)"&-.")+"(/,/'$(
and the posterolateral images of a femur. And then those
fracture images are segmented from background using level set
method. Considering the numerical errors and the instability
of evolution in conventional level set formulations, a distance 0"1/2!"&-3"/"%/'$(
regularization term and an external energy constraint term are "!/!$%8,(/"!'%--
used, which are able to maintain a desired shape of the level set 9!,%/2!"-:$;"5
function and speed up the motion of the zero level contour in *+,)"&- ,!/'/'$(
evolution process. After segmentation, the Canny edge detector
is used to extract the fracture edges on femur. The types of
femoral pertrochanteric fracture are classified by comparing
the difference of edges between reference normal images and the 45,&&'6'%,/'$(-7-3',)($&'&
testing images. Except the given four directions of 3D image, the
classification is processed automatically. Experimental results Fig. 1: The framework of pertrochanteric fracture automatic
illustrated the effectiveness of the proposed method. detection.

The incidence of femur fractures increased significantly Max/Min Rule, Product Rule, are fused to design as com-
among people over 60 years old. Most of these orthopedic bining classifier [4], [5]. Fracture is detected by computing
and trauma surgical interventions need careful classification the pixels value of each images column or row in [6], where
in order to decide the position and type of implant to be a threshold is set, there would be a fracture if the value is
used intraoperative. Automatic recognition and classification less than the threshold.
of femur fractures plays an important role in quantitative
In the above mentioned investigations, most of them either
only detect the fractures or design a general classifier, such
For the fracture clinical diagnosis is widely based on
as traverse fracture, open fracture, simple fracture and com-
computer-aided images, such as X-ray, CT, ultrasound and
minuted fracture. In this paper, a subtle pertrochanteric frac-
MRI images, many investigations on fracture detection and
ture classifier is proposed, which can distinguish five types
diagnosis are based on image processing. Morphological
of pertrochanteric fracture. The classification model is shown
gradient based image segmentation is used in [1] to detect
in Fig. 1, the original CT image is denoised and smoothed
radius bone fracture. Fracture detection is performed by a
by Gaussian filter, and then the distance regularization level
registered active shape model in [2], where the pelvic CT
set method is used to segment the region of interest (ROI).
images are preprocessed by adaptive windowing, bound-
After that, the Canny edge detection is used to detect the
ary tracing and wavelet transform. Stacked random forests
construction of femur and then the image is divided into
feature fusion is used in [3] to detect fracture in X-ray
several parts according to the definition of pertrochanteric
images. After edge and shape features are extracted from
bone, multiple classifiers, such as Back Propagation Neural
Network, K-Nearest Neightbour, Support Vector Machine, For there usually are noises in the segmentation, filters
are used to remove the smaller noise regions and edges
*Research supported by the grant from National Natural Science by mistaken segmentation as shown in Fig. 2. A continues
Foundation of China (NSFC) ( No. 61273256, No. 61305033 and No. region would be considered as a outliers if its size is less
L. Wang and H. Cheng are with Center for Robotics, University of than 10 10, and then this region would be moved out. A
Electronic Science and Technology of China, Chengdu, China 611731. continues line would be moved out if its length is less than
(email:, one forth of the width of each image. The pertrochanteric
H. Lan and Y. Zheng and K. Li are with Affiliated Hospital of
Chengdu University, Chengdu, China 610106. (email:, fracture is classified by comparing the difference of each, part with reference normal images.

978-1-4577-0220-4/16/$31.00 2016 IEEE 3851

!" #" $" (a) Two parts fracture (b) Three parts fracture 1

(c) Three parts fracture 2 (d) Four parts fracture

%" '" &"

Fig. 2: Image denoised. (a) is the original image, (b) is

segmented image by level set, (c) is the region of interest.
(d) is the extracted edges by Canny detector, (e) is the edges
in yellow rectangle region of (d), (f) is the lines of interest
(e) Five parts fracture 1 (f) Five parts fracture 2
in (e).


For the diagnosis of fracture, the types of femoral (g) Six parts fracture
pertrochanteric fractures are defined as five classes [7]: the
Fig. 3: Definition of Pertrochanteric Fracture.
two parts, three parts, four parts, five parts and six parts
fractures. In two parts fracture the fracture line is cross the
pertrochanteric, as shown in Fig. 3a, it is between in greater
trochanter and lesser trochanter. The three parts fracture is is derived as the gradient flow that minimizes an energy
defined as follows. There are fractures in greater trochanter functional. The energy function is consisted of a distance
or lesser trochanter go with two parts fracture, as shown regularization term and an external energy that drives the
in Fig. 3b and Fig. 3c. In four parts fracture, there are motion of the zero level set toward desired locations.
greater and lesser trochanter fractures go with two parts Let be a level set function defined in a domain , an
fracture, as shown in Fig. 3d. In five parts fracture, there energy function E() is define as
is anterior or posterior lateral fracture go with four parts
E() = R() + Eext (), (2)
fracture, as shown in Fig. 3e and Fig. 3f. In six parts
fracture, there is anterior and posterior lateral fractures go where > 0 is a constant, R() is the level set regularization
with four parts fracture, as shown in Fig. 3g. According to term and Eext () is an external energy that depends on the
this definition, only four images of each femur are used in data of interest.
following discussion, i.e. the anterior, the anterolateral, the The distance regularization term R() is defined with a
posterior and the posterolateral images of a femur.
potential function p(x) as R() = p()dx. It makes
III. I MAGE S EGMENTATION level set evolution has a unique forward-and-backward dif-
fusion effect and maintain a desired shape of the level
Level set method is a tool for numerical analysis of shapes, set function, particularly a signed distance profile near the
which is used to image segmentation from background zero level set. The distance regularization effect eliminates
widely. In two dimensions image, the level set method the need for reinitialization and thereby avoids its induced
aims to representing a closed curve by using a level set numerical errors. In order to maintain the signed distance
auxiliary function . is represented as the zero of by property = 1 only in a vicinity of the zero level set,
= (x, y)|(x, y) = 0. If the curve moves in the normal while keeping the as a constant, with = 0, at locations
direction with a speed v, then the level set function satisfies far away from the zero level set. The p(x) is a double-well
the level set equation function, which has two minimum values at x = 1 and x = 0.

It is defined as p(x) = (x 1)2 /2. Then the derivative of
= v||, (1)
t R() is
where | | is the Euclidean norm, t is time. = div(dp (||)), (3)
In the level set formulations, the level set function maybe
develops irregularities during its evolution, which may cause
here div() is the divergence operator and dp (x) = dp(x)
xdx .
numerical errors and eventually destroy the stability of evo-
The external energy function
lution. To overcome this difficulty, in [8], Li proposed

a variation level set formulation to regularize the level
Eext () = gH()dx + g()dx, (4)
set function during the evolution. The level set evolution

here R and > 0 are coefficients, g is an edge indicator
function of image I, which defined as g = (1+GI 2 ) and G

is a Gaussian kernel with standard deviation . The H and

are Heaviside function and Dirac delta function, which are
!" #" $" %" &"
introduced to speed up the motion of the zero level contour
in the evolution process and minimize the energy when the Fig. 4: Image segmentation and edge extraction. (a) The
zero level contour is located at the object boundaries. In original image. (b) The segmented image. (c) The edges of
practice, the and H are approximated by the following segmented image. (d) The skeletons of image. (e) The edges
smooth functions, in bone.
{ 1 [ ]
2 1 + cos( x
) , x6
(x) = (5)
[ ] According to the definition of the five fracture classes,
) , x6
1 x 1
2 1+ + sin( x the images are divided to several parts as intertrochanteric,
H(x) = 1, x> (6) greater trochanter section, lesser trochanter section, anterior

0, x < and posterior lateral femur section. As shown in Fig. 5, the
first row is the images of a reference normal femur in four
The standard method to minimize the energy function directions, where the green rectangles are regions of greater
E() is to find the steady state solution of the gradient flow trochanter, the red rectangles are regions of lesser trochanter,
equation the yellow rectangles are regions of anterior lateral femur, the
E black rectangles are regions of posterior lateral femur. The
= = div(dp (||)) + g() second row is the images of a trochanter fracture, the third
and forth rows are extracted edges from each part where

+()div(g ). (7) the skeletons are subtracted. Then the fracture is classified
by comparing the difference between the test image and
Given an initial 0 (x), the Eqn. (7) can be solved by an iter- reference image among the mentioned sections.
ative narrow-band implementation. The readers are referred Let I1 I4 are the four direction images of each patient,
to [8] for more details. The 2D images are segmented from H2 H6 are the hypothesis of two parts fracture to six parts
background by using this level set function. In this paper, fracture as defined in section II, F1 F4 are the above men-
the parameters of the segmentation model are set as follows. tioned four sections fracture, and N, Ng , Nr , Ny , Nk are the
The = 0.2/t, = 10, = 5, = 0.8, in Eqn. (7), (5) number of edges in skeleton, green block, red block, yellow
and (6), where t = 5 is the time step of implementation, block and black block, respectively. Then the diagnosis is
the = 5 is parameter of Gaussian kernel G. formulated as hypothesis testing as follows.

P (F1 = 1) = P (Ng > 1|I1 ) P (Ng > 1|I4 )

P (F2 = 1) = P (Nr > 1|I1 ) P (Nr > 1|I2 ) P (Nr > 1|I3 )
P (F3 = 1) = P (Ny > 1|I1 ) P (Ny > 1|I2 ) P (Ny > 1|I4 )
For the fracture diagnosis is based on the information of
P (F4 = 1) = P (Nk > 1|I3 )
edges on bone, the edge detector is used to extract the struc-
tural information from the segmented images. Among the
P (H2 = 1) = P (N > 1|I1 ) P (N > 1|I3 )
presented edge detection methods, the Canny edge detection
P (H4 = 1) = P (H2 = 1) P (F1 = 1) P (F2 = 1)
algorithm [9] is one of the most strictly defined methods that
P (H3 = 1) = P (H4 = 0) (P (F1 = 1) P (F2 = 1))
provides good and reliable detection. Owing to its optimality
P (H6 = 1) = P (H4 = 1) P (F3 = 1) P (F4 = 1)
to meet with the criteria for edge detection and the simplicity
P (H5 = 1) = P (H6 = 0) (P (F3 = 1) P (F4 = 1))
of process for implementation, it is used to extract the edges
on femoral trochanter fracture. The image is smoothed by
Gaussian filter and two threshold values [t1, t2] are used to
determine potential edges. In the following experiment, the VI. E XPERIMENTAL R ESULTS
threshold of Canny edge detector is set as [0.2, 0.35]. This section shows the results of the proposed classi-
A demo results of image segmentation and edge extraction fication model for real clinical images. 38 patients with
are shown in Fig. 4, where (a) is the original image, (b) is pertrochanteric fracture were collected, where there are
the segmented image, (c) is the edges of image, (d) is the 9, 6, 7, 14, 2 people with two parts to six parts fracture,
skeletons of image and (e) is the edges without skeleton. It respectively. Some samples are shown in Fig. 6. The original
is noted that the line in (d) is considered as a skeleton if it reconstructed 3D images from CT are 1024 1024 pixels,
is continues with external contour. Fig. 4 illustrated that the which are down-sampled to 256256 pixels. It is noted that,
algorithms of segmentation and edge extraction play good the size of segmented images is different from each other for
performance. the difference of viewpoint and difference of patient.

Fig. 5: The partials of images. The first row is the reference images of a normal femur, the second row is the test images
of a trochanter fracture, the third and the forth rows are the extracted edges from each part of the test images.

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This paper explore the pertrochanteric fracture classifica-
tion in 3D CT-images. A distance regularization level set
method is used to segment ROI from noisy background,
Canny edge detect operator is used to extract fracture edges,
and then by comparing the difference of edges between
reference normal images and testing images, the fracture is
classified according to the definition of pertrochanteric frac-
ture. Compared with existed works, the proposed method can
classify subtle fractures on pertrochanteric. The experimental
results illustrated the good performance of this method. In
future work, we will discuss the sparse feature representation
and supervised machine learning method on large data sets.