Feasibility of Dark-Field Radiography to Enhance Detection of Nondisplaced Fractures

Florian Schaff, Christoph Jud, Martin Dierolf, Benedikt Günther, Klaus Achterhold, Bernhard Gleich, Andreas Sauter, Klaus Woertler, Johannes Thalhammer, Felix Meurer, Jan Neumann, Franz Pfeiffer, Daniela Pfeiffer

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Many clinically relevant fractures are occult on conventional radiographs and therefore challenging to diagnose reliably. X-ray dark-field radiography is a developing method that uses x-ray scattering as an additional signal source. Purpose: To investigate whether x-ray dark-field radiography enhances the depiction of radiographically occult fractures in an experimental model compared with attenuation-based radiography alone and whether the directional dependence of dark-field signal impacts observer ratings. Materials and Methods: Four porcine loin ribs had nondisplaced fractures experimentally introduced. Microstructural changes were visually verified using high-spatial-resolution three-dimensional micro-CT. X-ray dark-field radiographs were obtained before and after fracture, with the before-fracture scans serving as control images. The presence of a fracture was scored by three observers using a six-point scale (6, surely; 5, very likely; 4, likely; 3, unlikely; 2, very unlikely; and 1, certainly not). Differences between scores based on attenuation radiographs alone (n = 96) and based on combined attenuation and dark-field radiographs (n = 96) were evaluated by using the DeLong method to compare areas under the receiver operating characteristic curve. The impact of the dark-field signal directional sensitivity on observer ratings was evaluated using the Wilcoxon test. The dark-field data were split into four groups (24 images per group) according to their sensitivity orientation and tested against each other. Musculoskeletal dark-field radiography was further demonstrated on human finger and foot specimens. Results: The addition of dark-field radiographs was found to increase the area under the receiver operating characteristic curve to 1 compared with an area under the receiver operating characteristic curve of 0.87 (95% CI: 0.80, 0.94) using attenuation-based radiographs alone (P < .001). There were similar observer ratings for the four different dark-field sensitivity orientations (P = .16–.65 between the groups). Conclusion: These results suggested that the inclusion of dark-field radiography has the potential to help enhance the detection of nondisplaced fractures compared with attenuation-based radiography alone.

Original languageEnglish
Article numbere231921
Issue number2
StatePublished - May 2024


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