COMPUTERIZED OSTEOPOROSIS DETECTION BY

CLAVICULAR CORTEX THICKNESS MEASUREMENT

J.T. Pramudito*, R.G. Wachjudi**, A.P. Widita*, T.R. Mengko*, S. Soegijoko, F.I. Muchtadi***

*Scool of Electrical Engineering & Informatics, Institut Teknologi Bandung

**Department of Internal Medicine, Hasan Sadikin Hospital, Bandung
*Faculty of Industrial Technology, Institut Teknologi Bandung

Abstract: Osteoporosis could infect every person,

man and woman, without considering their age. It
has caused a lot of very uncomfortable and
dangerous effects, such as pain, body impairment,
and even death. Therefore, preventive action
against osteoporosis is very important. Osteoporosis
diagnosis method which becomes the gold standard
until this time is Dual Energy X-Ray
Absorptiometry (DEXA), with the use of T-Score.
Unfortunately, DEXA is very expensive and rarely
found in remote areas hospitals in Indonesia. This
research project develops a software system which
could implement image enhancement, image noise
removal operation, edge detection, image rotation,
and clavicular cortex thickness measurement. The
input is thorax x-ray digital image and the output is
clavicular cortex thickness (in millimeter). Using
thorax x-ray image as input, this software system
provides cheaper osteoporosis diagnosis tools and
suitable to be used as osteoporosis screening method
which could detect osteoporosis earlier. Experiment
is performed to 46 digital thorax x-ray image.
Compared with the gold standard (DEXA), this
system shows 88.89% sensitivity, 90% specificity,
96.97% positive predictive value, 69.23% negative
predictive value, and 89.13% accuracy.
Introduction
Osteoporosis is a disease of the skeletons
characterized by low bone mass density and micro
architectural deterioration of bone tissue, leading to
enhanced bone fragility and a consequent increase in
fracture risk [1].
According to Indonesian Statistic National Bureau
in 2001, about 15 millions people in Indonesia have
been infected with osteoporosis and among them,
750.000 people suffered spine and hip fracture every
year [2].
Until a healthy person is around 40, the process of
breaking down and building up bone by cells called
osteoclasts and osteoblasts is a nearly perfectly coupled
system, with one phase stimulating the other. As a
person ages, or in the presence of certain conditions,
this system breaks down and the two processes become
out of sync. The reasons why this occurs during aging
are not clear. Some individuals have a very high

turnover rate of bone; some have a very gradual

turnover, but the breakdown of bone eventually
overtakes the build-up [3].
Histopatologically, osteoporosis is characterized by
the decreasing of bone cortex thickness and the
decreasing of bone trabecular quantity and/or quality.

Figure 1: Inside the brittle bone

The gold standard for osteoporosis diagnosis until

this time is Dual Energy X-Ray Absorptiometry
(DEXA). DEXA is used to measure the bone mineral
density (BMD) of the patients. Measurements of BMD
are given as mg/cm2, which is the average
concentration of bone mineral in the areas that are
scanned with the imaging tests. Using DEXA, BMD is
categorized by a T-score in reference to young normal
BMD.
To calculate a patients T-score, the patients
measured BMD is subtracted with BMD reference
range of women in their thirties (YN = young normal).
Around age 35, bone mass is usually at its peak and
fracture risk is at its lowest. The result is then divided
by the standard deviation (SD).
T-Score = (BMD YN) / SD

(1)

Table 1: WHO Criteria for Osteoporosis in Women

Normal

T-Score > -1.0

Low Bone Mass

(Osteopenia)
Osteoporosis

T-Score is -1.0 to -2.5

T-Score < -2.5

Unfortunately, DEXA is very expensive and rarely

found in remote areas hospitals in Indonesia, therefore
DEXA is not suitable to be used as early osteoporosis
detection method.

While the cost of fractures of hip, spine, and

forearm in terms of discomfort and functional loss, as
well as depression and other psychological problems is
high, earlier diagnosis and treatment would alleviate
some of this. Anything that would improve the earlier
diagnosing without increasing the cost would be
helpful.
Since the thorax x-ray is one of the most common
examinations in medical practice and costs cheaper, it
would make an ideal diagnostic tool if, at no additional
cost, it could be utilized in the diagnosis of
osteoporosis.
The purpose of this research is to develop an image
processing algorithm which can detect clavicular
cortex edges, measure the thickness, and then
implement the algorithm through a software system.
The algorithm is able to perform thorax x-ray digital
image enhancement operation, image noise removal
operation, edge detection, image rotation, and
clavicular cortex measurement. The software system
hopefully could be used as an alternative method for
early osteoporosis detection procedure, which is
cheaper and easier to use.

Figure 3: A general block diagram of the system

Thorax x-ray image is acquired from 46 patients,

with equal standardization procedure for each image
acquisition. The analog image is then digitalized using
CanoScan 9900F Canon Scanner. The digital image is
then saved in Windows Bitmap (*.bmp) file type,
grayscale (8 bit intensity), 800 dpi resolution, and in
32002400 pixel size.
The image is then used as input for the software
system. In the next section, we describe methods being
used in the system as seen in the block diagram in
figure 3.
1. Image Pre-Processing Operation
The purpose of this operation is to adjust the input
image so that the image could be processed in the next
operation. It includes image cropping, image
enhancement, and image noise removal.

Figure 2: A simplified block diagram of the system

First, the patients thorax x-ray image is acquired.

And then the analog image is digitalized using image
scanner, so that the image can be processed in a PC
(personal computer) where the software system
developed in this research is already installed. The
image becomes the input of the software system, and
the output of the system is clavicular cortex thickness
measurement results in millimeters. This measurement
result is then used by medical doctors to detect
osteoporosis, based on hypothesis that thickness
measurement result less than 3 mm is considered
having osteoporosis problem, while measurement
result more than and equal to 3 mm is considered
normal [2,4].
Materials and Methods
In this section, we describe the image processing
methods that is developed and used in this research and
also the development of the software system.
Image processing algorithm developed in this
research is designed using MATLAB. A general block
diagram which describes the system is given below:

1.1 Image Cropping

The input image needs to be cropped first because
we dont need other parts of the image. We only need
the area in the clavicular bone, located between the
projected medial margin of the scapula and the lateral
margin of the adjacent rib [2, 4]. Image cropping is also
useful for saving computation time by eliminating
unnecessary areas.

(a)

Figure 4: (a) Input Image

(b)

(b) Cropped Image

1.2 Image Histogram Modification

Histogram modification is one kind of image
enhancement technique. The purpose of it is to reduce
the effect of low contrast level of the image and to
normalize the image intensity level.
The method for histogram modification that is used
in this research is contrast stretching, which stretch the
distribution of grayscale intensity value in histogram
from 0 to 255.

(a)

(b)

Figure 5: (a) Image Histogram before Contrast Stretching

(b) Image Histogram after Contrast Stretching

column. The result is become the upper edge of

clavicular cortex.
Detecting the position of the highest image
intensity of the vertical gradient image for each
column. The result is become the lower edge of
clavicular cortex.
The result form this algorithm is still an early edge
detection, because the edges is still separated from
each other.

1.3 Image Noise Removal

The image is containing noise that comes from the
x-ray film, a sequence of vertical lines with the same
width and period. These lines are removed by using the
smoothing effect of 1-dimensional Gaussian Function
Filtering horizontally.

G( x)

1
2

x2
2
2

exp

(2)

G(x) = Gaussian Function;

= Standard Deviation

(a)

(c)

(b)

Figure 6: (a) Cropped Image (b) Image after Contrast

Stretching (c) Image after Gaussian Filtering

2. Region of Interest (ROI) Segmentation

The purpose of ROI segmentation operation is to
detect the clavicular cortex edges and separate them
from other part of the image. This process is needed
before we continue to the next operation (feature
extraction).
ROI segmentation is done with finding the
clavicular cortex edges, then rotating the image to a
certain degree so that the cortex clavicular position is
standardized and the measuring result could be more
accurate and precise, and finally linking the edges
which were still separated from each other.
2.1 Clavicular Cortex Edge Detection
The edge detection algorithm is performed like this:
Creating vertical gradient image
The output image from pre-processing operation
is then filtered with 1-dimensional Gaussian
Function differential vertically.

G ' ( y)

y
2 3

y2
2
2

exp

(3)

G(y) = Gaussian Function differential;

= Standard Deviation
Detecting the position of the lowest image
intensity of the vertical gradient image for each

(b)

(a)

Figure 7: (a) Image before edge detection

(b) Image after edge detection

2.2 Image Rotation

The purpose of image rotation is to standardize the
position of the clavicular cortex and make the
measurement result more accurate and precise.
Clavicular cortex edges that we get from earlier
operation, is creating an angle ( degree) compared to
horizontal reference line.
First step to do is to find a representation linear line
of the clavicular cortex edges. This linear line is
created from linear regression operation from upper
clavicular cortex edge point coordinates. Then we
compare the linear line with the horizontal reference
line to get the rotation angle ()
horizontal
reference line

linear line representing

edge
Figure 8: Measurement of rotation angle
The image is then rotated for using following
transformation equation:

x
cos( ) sin( )
y sin( ) cos( )

x
y

(4)

2.3 Edge Linking Algorithm

After we rotate the image, the next operation is to
make the separated clavicular cortex edges connected
to each other. An edge is boundaries connected to each
other which give specific characteristics to the shape of
an object [5]. Therefore edge boundaries should be well
connected.
The algorithm is performed like this:
Detecting segment of the clavicular cortex edge
which is not connected
In detecting the unconnected segment, we find
points that dont have another neighbor point from
the directions of up, bottom, right, or left. Then we

collect the coordinates of those points, so that we

know the position of each unconnected point.

The result of all segmentation operation is given

below:

(a)

Figure 9: Detecting unconnected points

Comparing an unconnected point to another

unconnected point near it
After the positions of all points are collected, then
we compare the first unconnected point to another
unconnected point near it. For example, point 1 is
compared to point 2, and then point 1 is compared
to point 3, and then point 1 is compared to point 4,
and so on. The comparation is the distance
between the two points. The distance itself is
resulted from computation with the function:

1
x 2 y 2
9

(b)

(c)

Figure 12: (a) Image after Edge Detection Operation

(b) Rotated Image (c) Image after Edge Linking Operation

(5)

d = distance; x = horizontal range;

y = vertical range
This distance function has meaning: point which
has more far distance horizontally is preferable
than point which has more far distance vertically.

Figure 10: Physical explanation of the function

Pick the next point which has nearest distance

The next step is to pick the nearest point to the
first point, from the result of comparation
operation.
Connecting the points (edge linking)
The final step is to connect two points that have
the nearest distance. For example, after we
compare point 1 to point 2, point 1 to point 4, and
point 1 to point 5, then we gets the distance of
each comparation, we find that the lowest value of
the distance is from point 1 to point 5. Therefore,
we then connect point 1 with point 5.

3. Feature Extraction
The purpose of feature extraction operation is to
measure the thickness of clavicular cortex. From
segmentation operation, we have an image that only
contains of the clavicular cortex. So the final step
needed is to find the distance between upper cortex and
lower cortex.
The distance is measured by subtracting the vertical
position of point coordinates from each pixel in upper
cortex with vertical position of point coordinates from
each pixel in lower cortex.
d y uppercortex y lowercorte x
(6)
In this research, we dont use all of the distance
measurement. We only use three measurement
sampling. The purpose is to give a better measurement
result rather than use the average value of all point
distance measurement. So we only measure the
distance in three positions of point coordinates.
The result of distance measurement is still in pixel
value, while the measurement result that we need is in
millimeters value. So we have to perform certain
conversion.
The conversion is performed like this:
The image resolution is 800 dpi
It means that 1 inch is equal to 800 pixels, or 1
pixel is equal to 1/800 inch.
So each pixel is equal to 25.4/800 mm
Therefore,
we
multiply
the
distance
measurement result with 25.4/800

(a)

(b)

(c)

Figure 13: (a) Image after Edge Linking Operation

(b) Three measurement sampling (c) Final Image

Figure 11: Edge Linking

Results
Implementation of the image processing algorithm
to an independent software system through an
implementation of a Graphics User Interface (GUI),
will make the clavicular cortex thickness measurement
easier, without using such a complex and heavy
software like MATLAB.
The software system is implemented using
Microsoft Visual C++ 6.0 software developer, using
CxImage image library.
The specification of the system is:
Software system is compatible with Microsoft
Windows 98 SE, Windows 2000, Windows
ME, and Windows XP Operating System
Minimum PC criteria that should be used are
Pentium 500 MHz, 32 RAM, and graphic card
VGA 8 MB with monitor that can apply
1024768 screen resolution.
Input of software system is thorax x-ray
digital image, using Windows Bitmap (*.bmp)
format, 8 bit (grayscale) or 24 bit (RGB)
intensity level, and having 32002400 pixel
image size.
Output of software system is clavicular cortex
thickness measurement in millimeters.
Software system is equipped with undo/redo
operation, reset operation, and save operation.

Thickness measurement < 3mm is considered

osteoporosis
Thickness measurement 3mm is considered
normal
T-Score < -1 is considered osteoporosis
T-Score -1 is considered normal
Experiment is performed to 46 thorax x-ray image.
The result of the experiment is shown in table 2.
Table 2: Experiment Result

From the experiment result, we could analyze the

system performance. The performance is stated in five
parameters:
Sensitivity
= 88.89 %
Specificity
= 90 %
Positive predictive value
= 96.97 %
Negative predictive value = 69.23 %
Accuration Rate
= 89.13 %
Conclusions
In this research, we develop a software system to
measure the thickness of clavicular cortex, from an
input of thorax x-ray image, as an early osteoporosis
detection method. The software system could
implement image processing operations such as: image
contrast level enhancement, image noise removal,
clavicular cortex edge detection, image rotation, edge
linking, and image extraction (measuring the thickness
of clavicular cortex). The software system could be
used as osteoporosis screening method for early
detection of osteoporosis.
References

Figure 14: The Software System

Discussion
In this section, we will describe the experiment that
is conducted to find the software system performance.
The experiment is performed by comparing the
software systems measurement results (the thickness
of clavicular cortex in millimeters) with the T-Score
resulted from prior patients examination using DEXA
as the gold standard of osteoporosis diagnosing
method.
Criteria used for analyzing the comparation result
are:

[1] SANKARAN B. (2000): Osteoporosis, (Novelty

Printers, Mumbai)
[2] SARININGSIH. (2004): Osteoporosis diagnosis
using clavicular cortex thickness measurement,
compared with DEXA measurement, (Padjadjaran
University Medical School, Bandung)
[3]
HARVEY, SIMON,
MD,
Osteoporosis:
http://www.adam.com
[4] NATHAN, M.H, M.D, Osteoporosis Diagnosed by
Clavicular
Cortex:
http://members.lycos.co.uk/
jamusnet1/testfordad/index.htm
[5] JAIN, ANIL K. (1989): Fundamentals of Digital
Image Processing, (Prentice Hall, Singapore)
[6] DANUDIRDJO, DONNY. (2005): Design and
Implementation of Osteoarthritis Diagnosis Software
System by Detection of Knee Joint Stiffness, (Dept. of
Electrical Engineering, ITB, Bandung)