title: Missed subtle fractures on the trauma-meeting digital projector.
abstract: BACKGROUND
  Since the introduction of digital X-rays, many orthopaedic departments have used digital projection systems to display diagnostic images during discussion, there has been no published work directly comparing the sensitivity high resolution diagnostic monitors with standard digital projection systems in the context of orthopaedic injuries.
  
  
  METHODS
  Participants were asked to review AP pelvic radiographs of non-displaced hip fractures on the department's digital projector and again on a diagnostic monitor, results were compared to determine if a true difference in sensitivity between the imaging modalities existed.
  
  
  RESULTS
  A significant difference in the sensitivity of the diagnostic monitor and meeting room projector was found, 0.85 vs 0.55, respectively (95% CI 0.78-0.89 vs 0.47-0.63); absolute difference 0.3 (95% CI 0.28-0.32, p≤0.001). Inter-observer agreement was moderate.
  
  
  CONCLUSIONS
  A difference in sensitivity was demonstrated to a high level of statistical power, and a positive result on either modality was highly likely to represent a true fracture, however a fracture cannot be confidently excluded examining a single image using the digital projector alone. The study was limited to a single view of one particular fracture type and may not be generalisable to all types of subtle fracture; in addition, the retrospective nature of the image review means that the sensitivity figures cannot be applied to a presenting patient population.
  
  
  CONCLUSIONS
  This study demonstrates a significant difference in sensitivity between the two display types which may have implications with regard to reducing delays and unnecessary further imaging if clinicians are not aware of this potential limitation. Clinicians, if clinically suspicious of a fracture should always seek to review the images on a validated PACS display device if a fracture is not seen on a non-validated device. Departments should evaluate their current equipment, consider what equipment is available, what is the most suitable equipment for the environment in which it is being used and what the potential implications for patient care may be as a result.
authors.affiliation: Department of Trauma and Orthopaedics, Yorkshire and Humber Deanery, c/o 9th Floor Orthopaedic Meeting Room, Hull Royal Infirmary, Anlaby Road, Hull, East Riding of Yorkshire HU3 2JZ, United Kingdom. Electronic address: mrchellam@sky.com.
authors.forename: W B
authors.initials: WB
authors.lastname: Chellam
mesh_terms: D006620:Hip Fractures / Q000000981:diagnostic imaging* / Q000473:pathology; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000295:instrumentation; D015588:Observer Variation; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed
keywords: Accuracy; Display; Fracture; Hip; Neck of Femur; PACS; Projector; Sensitivity