Virtual Reality for Detailed Visualization and Generation of Proximal

and Distal Bone Fracture Patterns

J. J. Jim

enez-Delgado

1 a

, F. D. P

erez-Cano

1 b

, G. Parra-Cabrera

1 c

and I. Remolar-Quintana

2 d

Department of Computer Science, University of Ja

en, Ja

en, Spain

Institute of New Imaging Technologies, Universitat Jaume I, Castell

on, Spain

Keywords:

Bone, Fracture, Pattern, Virtual Reality, Usability, Interaction.

Abstract:

This paper articulates the application of virtual reality (VR) in facilitating the study of bone fractures, particu-

larly those affecting the proximal and distal end segments of long bones, areas of the bone in which there are a

large number of irregularities. With the increasing prevalence of bone fractures due to aging and increased life

expectancy, we present an innovative virtual reality system that meticulously generates and visualizes bone

fracture patterns in three dimensions. The system allows users, including healthcare professionals, to interact

with 3D bone models and delineate fracture patterns in a realistic environment. It features haptic feedback,

simulating the sensation of drawing on a real bone. The tool also provides an exporting functionality for the

drawn fractures, enabling the integration into other medical platforms. Experts have evaluated the interaction

and representation of the fracture patterns in a highly positive evaluation. The experts assessed the system

positively, emphasizing its potential towards enhancing surgical planning, improving patient outcomes, and

fostering educational advancements. Future work aims at improving the degree of realism within the VR en-

vironment and reﬁning the precision of closing fracture lines.

1 INTRODUCTION

The increase in life expectancy has led to a higher in-

cidence of fractures, mainly due to the gradual wear

and tear associated with daily activities. This natu-

ral aging process often weakens bones, making them

more susceptible to fractures. A complicating fac-

tor in the treatment of fractures is the interference of

blood at the site of the injury, which can obscure the

surgeon’s view and make it difﬁcult to align the bone

fragments. As a result, secondary surgeries are often

required to properly realign these fragments.

The elderly are particularly at risk for hip frac-

tures, an injury that poses signiﬁcant health risks and

can lead to serious consequences such as reduced mo-

bility and increased dependency. These fractures are

particularly challenging due to the complex nature of

the hip joint and the essential role it plays in weight

bearing and movement. Therefore, in this work we

will focus on the use of long bones, with particular

https://orcid.org/0000-0003-3014-0496

https://orcid.org/0000-0002-8065-8173

https://orcid.org/0000-0003-0364-8657

https://orcid.org/0000-0002-7743-2579

emphasis on the use of the femur, as it is one of the

most common fractures and has the greatest impact

on people.

The study of bone fractures helps to understand

the nature and morphology of these injuries, which is

crucial for the development of effective and person-

alized therapeutic strategies. In this context, virtual

reality is emerging as an innovative tool that is revo-

lutionizing the study of bone fractures. The applica-

tion of virtual reality in the medical ﬁeld allows health

care professionals to visualize the complex anatomy

of bone fractures in three dimensions. This facilitates

a deeper analysis of the unique characteristics of each

fracture, such as the orientation of the fracture lines,

the dispersion of the bone fragments, and the struc-

tural integrity of the affected bone, as well as improv-

ing the precision of surgical planning and patient out-

comes.

The proximal and distal segments of bones typi-

cally exhibit numerous irregularities, making it quite

complex to draw a fracture pattern in these areas. The

common approach involves creating a 2D design and

mapping or projecting it onto the bone model (Parra-

Cabrera et al., 2022). However, the traditional method

cannot be effectively applied in these bone regions,

300

Jiménez-Delgado, J., Pérez-Cano, F., Parra-Cabrera, G. and Remolar-Quintana, I.

Virtual Reality for Detailed Visualization and Generation of Proximal and Distal Bone Fracture Patterns.

DOI: 10.5220/0012446500003660

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 19th International Joint Conference on Computer Vision, Imaging and Computer Graphics Theory and Applications (VISIGRAPP 2024) - Volume 1: GRAPP, HUCAPP

and IVAPP, pages 300-306

ISBN: 978-989-758-679-8; ISSN: 2184-4321

often necessitating the use of 3D drawing devices,

such as haptic devices. This work presents a vir-

tual environment for drawing a wide range of frac-

ture patterns, including the most deformed areas of

human bones, for export and use in other medical

tools. The VR allows us to generate a three dimen-

sional interactive environment for detailed visualiza-

tion of fractures, including the orientation of fracture

lines and deformities on the bone surface. It is par-

ticularly useful for examining complex areas of bone

fractures, such as the proximal and distal end seg-

ments. The tool also allows healthcare profession-

als to export these fracture patterns for use in other

medical tools. It enables healthcare professionals to

meticulously examine the anatomical intricacies and

complexities of fractures within challenging anatomi-

cal regions, such as the proximal and distal ends of

bones. This precise, 3D visualization fosters com-

prehension of the speciﬁc fracture geometry, empow-

ering surgeons to devise tailored surgical strategies.

Moreover, it furnishes aspiring surgeons with an inter-

active tool for honing practical skills, enabling them

to practice fracture identiﬁcation and treatment within

virtual environments prior to real clinical scenarios.

The outline of this work is as follows: In the next

section, we analyze the previous work on medical ap-

plications in virtual reality. After the background,

the materials used and the system developed are de-

scribed in detail. The following sections present and

discuss the results obtained in the process of using

the simulator. Finally, the conclusions summarize the

main advances and lines of work for the future.

2 RELATED WORK

Progress in bone fractures is essential for the diagno-

sis and recovery of the patients. These studies con-

tribute to improving practices and technologies for

treating fractures, including ﬁxation methods, plates,

screws, and prostheses. The study of bone fractures

from a forensic and anthropological perspective re-

veals crucial information to determine the cause of

death or the lifestyle of the subject, as each bone and

fracture is unique and the anatomy of the fracture

varies according to various biological factors such

as age, bone density and diseases that affect bone

strength (Jones, 2010; Azar et al., 2020). Although

they are different, there are certain patterns in their

shape when they are produced under similar condi-

tions (P

erez-Cano et al., 2023). AO Trauma Inter-

national and Orthopaedic Trauma Association Rep-

resentatives (AO/OTA) presented a compendium for

the classiﬁcation of bone fractures and dislocations

(Meinberg et al., 2018). The number of pieces of bone

detached, the angle and the shape of the fracture lines

are the elements that allow differentiating the differ-

ent types of bone fractures. However, the shape of

the bone is not uniform and the areas with the most

irregularities are those where it is most difﬁcult to ex-

tract a fracture pattern for replication in another clin-

ical case. In the case of long bones, the irregularities

are usually found at the ends of the bone, that is, the

proximal and the distal end segments of the bone (Fig.

1).

Figure 1: The areas of a long bone in which a fracture is

likely to occur.

Several authors emphasize the importance of us-

ing new technologies to achieve realistic visualization

when conducting a medical simulation (Tsai et al.,

2001; Citak et al., 2008; Vaughan et al., 2016; Gu-

sai et al., 2017; Negrillo-C

ardenas et al., 2021; Fu

et al., 2022; Loetscher et al., 2023). Citak et al. (Citak

et al., 2008) concluded that the use of technology to

improve visualization and interaction allowed them to

improve the planning of a bone fracture reduction by

obtaining a more accurate result in the surgical pro-

cess. Tsai (Tsai et al., 2001) also concludes that simu-

lations in a virtual environment allow better planning,

mainly by improving the visualization of the fracture

area. Florence A

ım et al. (A

ım et al., 2016) have

demonstrated the effectiveness and advantages of us-

ing VR to train new surgeons. However, most virtual

reality based studies have focused on fracture reduc-

tion planning and training.

Some authors report that the use of VR also helps

participants to feel motivated and interested in partici-

pating in this type of projects (Herne et al., 2022; Reer

et al., 2022). Among other aspects, immersion, inter-

action and feedback are highlighted as fundamental

elements. Herne et al. (Herne et al., 2022) emphasize

the importance of feedback in providing a good expe-

Virtual Reality for Detailed Visualization and Generation of Proximal and Distal Bone Fracture Patterns

301

rience to the user who tries the tool. Gusay et al. (Gu-

sai et al., 2017) focused on analyzing the interaction

of a user in a realistic environment. In this work, they

analyze the different ways a user can interact with the

environment using different devices compatible with

the HTC Vive head-mounted display (HMD) to visu-

alize the scene.

Negrillo et al. (Negrillo-C

ardenas et al., 2021) de-

veloped a fracture reduction system based on VR us-

ing contralateral fractures as targets. They observed a

high learning rate when using the system and a reduc-

tion in simulation time as more trials were performed.

Vaughan et al. (Vaughan et al., 2016) reviewed the

main existing fracture reduction simulation environ-

ments, as well as the problems with some of them.

In this study, the authors also conclude that there is

strong evidence that the skill level of trainees in med-

ical procedures can be assessed using VR simulators.

Akhtar et al. (Akhtar et al., 2015) demonstrate the va-

lidity of a haptic VR trauma simulator, with surgeons

performing the procedure most often performing best

on the simulator. Homma et al. (Homma et al., 2019)

also worked along these lines and came to the same

conclusion.

Loetscher et al. (Loetscher et al., 2023) conducted

a recent study in which they concluded that there is

evidence that the integration of virtual reality in the

medical ﬁeld is extremely beneﬁcial and that it should

be used more often to take full advantage of its bene-

ﬁts. Some companies, such as Meta, are moving in

this direction to provide ecosystems to support the

growth of virtual reality in the medical ﬁeld. How-

ever, it is a process that will take some time before it

becomes a necessity for healthcare.

3 MATERIAL AND METHOD

The project was developed using the Unity engine, a

leading game engine known for its ability to support

interactive 3D content and broad cross-platform com-

patibility. The virtual reality experience was delivered

through the HTC Vive Pro Kit, chosen for its high-

resolution display and advanced tracking capabilities.

By using the advanced Lighthouse tracking system,

also known as base stations, we obtain a millimetric

accuracy for user positioning. This level of accuracy

makes this VR system ideal for simulating the intrica-

cies of an operating room environment. The immer-

sive experience is further enhanced by the wide range

of hardware sensors, including proximity sensors, gy-

roscopes, and infrared sensors. In addition, the con-

trollers are designed to provide seamless interaction

with the virtual environment. They incorporate tac-

tile feedback through vibration, allowing precise ma-

nipulation of three-dimensional objects, such as hu-

man bones in our simulation. The user can interact

with the environment using two controllers held in the

right and left hands. The equipment used to support

the virtual reality application consists of a computer

equipped with an i7 microprocessor, 8GB of RAM,

and an NVidia 1060 graphics card.

The virtual environment design consists of an op-

erating room (Fig. 2). A familiar space has been

recreated for the surgeons to increase the level of im-

mersion. The primary function of our tool is to allow

the user to delineate and examine fracture patterns on

highly detailed 3D models of long bones, focusing on

the complex and irregular areas such as the proximal

and distal end segments. The user can select between

different long bone models to draw a fracture using

the controllers.

Figure 2: Environment used to conduct the simulation.

The left controller allows the user to move around

the environment and move the model to improve the

viewing angle, while the right controller allows the

user to create the fracture pattern. To create a fracture

pattern, the controllers emit a laser beam in the direc-

tion they are pointed. When this laser intersects the

bone model, it creates a visible line on the bone sur-

face that represents the fracture line. The points form-

ing the fracture line are calculated by the intersection

between the mesh and the beam leaving the controller,

using the algorithm of M

oller and Trumbore (M

oller

and Trumbore, 1997). The user must hold down the

trigger to add points to the polyline that deﬁnes the

fracture line (Fig. 4). In addition, the fracture line

must be fully closed and connected for the fracture to

be valid and exported. It is not necessary to draw the

line in one go, the user can add points to the fracture

line one at a time and conﬁrm when the fracture rep-

resentation is complete. This mechanism facilitates

the elimination of incorrect points marked by the user,

since a history of the various iterations with the model

and the points selected is stored, so that errors can

be corrected as the fracture line is drawn. Figure 3

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302

shows the graphical interface that can be used by the

user within the virtual environment when drawing the

fracture pattern on a human bone. Moreover, the user

deﬁnes the end of the representation of the model and

it is automatically validated by a study of the continu-

ity of the polyline. If the polyline is not closed, the

user is prompted to continue with the design of the

pattern.

Haptic feedback is integrated to enhance the tac-

tile experience, giving the user the sensation of draw-

ing on a real bone through small vibrations. This fea-

ture is particularly useful for medical professionals, as

it adds a layer of realism that is critical to understand-

ing the physical characteristics of bone fractures. The

intensity of the vibration is slightly increased when

the user is drawing the fracture line and it is in a hole

or a bump is found in the geometry of the model. The

vibrations are managed by assessing the distance vari-

ations between the position of the controller and the

speciﬁc point on the bone model where the laser beam

intersects during the drawing activity. When the user

move the laser over the bone’s surface, the occurrence

and intensity of vibrations depend on the difference in

distance between consecutive points along the frac-

ture line.

An essential feature of this tool is the ability to

export the drawn fracture lines. This functionality al-

lows the fracture patterns to be integrated into other

tools. For this purpose, we have exported the point

cloud drawn by the user. We are currently working

on the import of the fracture lines generated in this

tool, so that it will not only serve to generate fracture

patterns, but also to improve the visualization or the

lines of existing patterns obtained with this or other

medical tools.

4 RESULTS

The previous section has detailed the development of

a virtual reality application to delineate and examine

fracture patterns on highly detailed 3D models of long

bones, speciﬁcally focusing on the complex and irreg-

ular areas of the bone surface. In this section we show

the result obtained and we focus on the evaluation of

the results obtained and how to analyze them to vali-

date the quality of the system designed. For this pur-

pose, we have conducted extensive tests to validate

the application.

There is no other system with a similar purpose.

Therefore, the design and functionality have been re-

ﬁned in collaboration with three specialists with ex-

perience in bone fracture reduction, a physiothera-

pist and an orthopedic surgeon. Each of the 5 users

was tasked to replicating a fracture type from the

AO/OTA classiﬁcation in the proximal and and dis-

tal area of three different bones: a femur, a humerus

and a ﬁbula. The ﬁbula can be considered the sim-

plest model, given that the deformity at the ends is

smaller. It has been presented as the initial case to

test the developed tool. The humerus and femur ex-

hibit more signiﬁcant deformities, with the femur be-

ing the most irregularly shaped and representing the

most complex case presented to the specialists. Each

bone has a different shape in these sections. Before

starting the tests, they were instructed on the controls

necessary to select the bone, rotate it and how to draw

the fracture line on it using the HTC Vive controllers.

Technical testing focused on system performance, sta-

bility, immersion and user interface usability.

Figure 5 shows different fracture patterns drawn

by experts on the end segment of the epiphysis of a

human humerus. All the patterns are based on the

AO/OTA classiﬁcation (Meinberg et al., 2018). The

image shows all the fracture lines that make up the

pattern in red. In addition, the lines drawn on the

back of the model, the non-visible part of the geom-

etry, are shown so that the user can take them into

account when closing the lines completely. Figure

5a represents an oblique fracture in the surgical neck

area. Figure 5b shows a wedge-shaped fracture with-

out fragmentation at the head of the humerus while

ﬁgure 5c shows a compound fracture with many frag-

ments in the same area. The visual improvement

is considerable when deﬁning the patterns, since the

simulator allows the deformations of the bone surface

to be identiﬁed with a high level of detail. Figure 6b

shows the view of the fracture pattern from the lon-

gitudinal axis of the bone on which it is drawn (Fig

6a.).

A survey was used to evaluate the tool using a 5-

item Likert scale. Table 1 shows the median and av-

erage results obtained through the survey in the dif-

ferent aspects considered. In general, most aspects

were rated positively by the expert group. Among the

main evaluations, the scores for the interface and the

drawing of fracture lines on the bone model stand out,

where all experts agreed with the maximum score.

This reﬂects the fact that the developed tool has an

intuitive interface and sufﬁcient functionality to draw

the patterns in the most complex areas in a simple

way.

We can see how the complexity increases when it

comes to completely closing the fracture lines in the

questions about painting the fracture lines. The high

precision of the controls makes it a complex task to

completely close the fracture line, as the start and end

points did not coincide. Achieving this task demands

Virtual Reality for Detailed Visualization and Generation of Proximal and Distal Bone Fracture Patterns

303

Figure 3: Editor interface for drawing fracture patterns. a) Bone selection menu, b) Drawing conﬁguration menu, and c)

Fracture line deletion submenu.

Figure 4: Interaction system to draw the fracture bone pat-

tern using the controllers.

Table 1: Results of the user experience survey in the VR

environment.

Item Median Average

Interaction 5 4,6±0,49

Interface 5 5

Draw fracture lines 5 5

Join fracture lines 4 4±0,40

Close fracture lines 4 3,8±0,40

Delete fracture lines 5 4,6±0,49

Learning curve 3 3,4±0,49

Immersion and realism 3 3,2±0,40

Fluency 5 5

signiﬁcant user dexterity. In the future, an automated

system will be incorporated to assist users in closing

the fracture line.

The degree of realism and immersion of the tool

and the learning curve stand out as the worst aspects

evaluated by the experts. The experts informed us

that the enhancement in bone visualization is signif-

icant, but they noted that the environment surround-

ing the bone fell short of resembling a real operating

room. This is due to the fact that the tool was de-

signed to improve the visualization of fracture lines

and deformities on bone surfaces, somewhat omitting

the environment in which the simulation was devel-

oped. Therefore, this is an aspect that needs improve-

ment in the future. On the other hand, although the

interaction mechanisms were rated as intuitive, repro-

ducing a clinical case without training the user is not

trivial. The initial training proved insufﬁcient to facil-

itate rapid and accurate pattern drawing. However, as

participants advanced through the tests, the rendering

of fracture patterns became quicker and more precise,

resulting in a reduction of poorly drawn lines during

the process. In future versions, an initial scene will

be included to train users in the use of the tool and to

facilitate the drawing process.

Subsequently, the experts were asked to perform

the same tests with a keyboard and mouse without a

virtual reality environment. Table 2 presents feedback

obtained by the experts after assessing the system

without the virtual environment. While they noted

that the new system was more comfortable, the inter-

action to draw the fracture patterns and the visualiza-

tion was noticeably inferior. Achieving a speciﬁc per-

spective for model visualization proved to be a rather

tedious task with the mouse. Moreover, the accuracy

in drawing lines was not as precise as in the VR envi-

ronment. As depicted, the scores decrease in almost

all aspects evaluated. However, the learning curve is

lower than in the virtual reality-based system. This

may be attributed to users being more accustomed to

use this type of device for interaction with a 3D envi-

ronment.

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304

Figure 5: Different fracture patterns drawn in the end segment of the epiphysis of a human humerus. a) Represents an oblique

fracture, b) a intact wedge fracture and c) a fragmentary fracture.

Figure 6: a) Fracture pattern on a bone model. b) Frac-

ture pattern observed from the longitudinal axis of the bone

model.

Table 2: Results of the user experience survey without the

VR environment.

Item Median Average

Interaction 5 4,6±0,49

Interface 5 5

Draw fracture lines 3 3,4±0,49

Join fracture lines 3 3±0,63

Close fracture lines 3 2,6±0,8

Delete fracture lines 5 4,8±0,4

Learning curve 4 4,4±0,49

Immersion and realism 3 3 ±0

Fluency 5 5

5 DISCUSSION

VR allows users to interact with 3D models of frac-

tures in an immersive environment, providing a more

realistic and robust understanding of fracture charac-

teristics compared to traditional 2D imaging methods.

This includes understanding complex structures, ori-

entations of fracture lines, bone deformities, and de-

tails about bone fragment dispersion.

As the VR environment allows users to modify

viewing angles freely, this assists in creating precise

surgical plans as one can explore the fracture from

various perspectives that might not be possible with

traditional imaging. The capability to draw fracture

lines directly on the 3D bone models within the VR

environment also enhances the precision and person-

alization of surgical planning.

Haptic feedback is integrated into the VR tool,

providing the sensation of drawing on a real bone

surface via vibrations, improving the tactile realism.

This can be particularly useful for tactile learners and

enhances the overall understanding of the physical

characteristics of the bone and fractures. Further-

more, since the VR tool allows exporting of fracture

patterns, these can be integrated with other medical

tools or simulations, which can boost surgical plan-

ning or training processes.

The primary advantage, however, is that VR gives

the potential to rehearse, repeat, and correct pro-

cedures virtually before performing actual surgery,

which can improve the likelihood of positive patient

outcomes.

6 CONCLUSIONS AND FUTURE

WORK

This research has successfully demonstrated the ap-

plication of VR in the medical ﬁeld, particularly in

the study of bone fractures. We have created a sys-

tem that allows medical professionals to visualize and

interact with 3D models of long bones to draw frac-

ture patterns. This technology has proven to be par-

ticularly effective in examining the complex areas of

bone fractures, such as the proximal and distal end

segments.

Virtual Reality for Detailed Visualization and Generation of Proximal and Distal Bone Fracture Patterns

305

The application developed signiﬁcantly improves

the visualization of bone deformities as well as the in-

teraction to represent different clinical cases of frac-

ture on human bones. In addition, haptic feedback

is included when drawing, using the changes in the

geometry of the model. The ability to draw and ma-

nipulate fracture lines directly on the bone models

has been highly rated by experts, reﬂecting the rel-

evance in medical practice. Moreover, the ability to

export these fracture patterns enhances its application

in various medical scenarios, extending its utility be-

yond mere visualization. These patterns can be used

in other medical tools, facilitating a more comprehen-

sive use in diagnostics, treatment planning, and edu-

cational purposes.

The extension of the variety of patterns generated

with the tool enables a wider range of fractures to be

covered. This is a key element as the extension makes

it possible to work with a wider range of medical sce-

narios or generate databases with more accurate infor-

mation about the fracture area.

However, certain challenges such as the precision

in closing fracture lines and the degree of realism and

immersion need to be addressed. While the tool ex-

cels in visualizing fracture lines and bone deformities,

improvements in the simulation environment and user

training are required for a more comprehensive appli-

cation.

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